Menopausal Treatment Options for Migraine with Aura Sufferers

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Menopause is often accompanied by debilitating symptoms like hot flashes and sleep disturbances. For women who also experience migraines, particularly migraines with aura, navigating menopause can be even more challenging.

Understanding Migraine with Aura

Migraine with aura is a type of migraine characterized by neurological symptoms, most commonly visual disturbances, that precede the headache. These auras can include seeing flashing lights, zigzag lines, or experiencing blind spots. These are examples of simple visual auras, but some migraine sufferers experience complex auras that cause numbness, confusion, slurred speech, inability to think clearly, or more significant visual disturbances (1). The Longitudinal Women's Health Study showed that higher aura frequency is also associated with a higher risk of stroke. Migraine sufferers with less than one aura per month were half as likely to experience a stroke than those with more than one aura per week (2). We don't yet clearly understand why migraine with aura increases the risk of stroke.

The Impact of Menopause on Migraines

Perimenopause, the months or years leading up to menopause, can be an especially troubling time for migraine sufferers. Hormonal fluctuations, particularly a drop in estrogen levels, may trigger more frequent and severe migraine attacks during this transition. However, the majority of postmenopausal women do report an overall reduction in the number of migraines.

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Treatment Options

When it comes to treating migraines in menopausal women, the goal is to manage both the menopause symptoms and the migraines. Here are some strategies:

1. Non-hormonal preventive agents: Treatments for the daily prevention of migraines include antiepileptic drugs, beta-blockers, antidepressants, and calcitonin gene-related peptide blocking medications. Non-hormonal treatments for the vasomotor symptoms of menopause include SSRIs, SNRIs, gabapentin, oxybutynin, and clonidine. Of these, venlafaxine (3), gabapentin (4), and clonidine (5) may be especially beneficial for migraine sufferers.

2. Menopausal Hormone Therapy (MHT): While MHT for those with migraines with aura has been controversial due to its side effect profile, it can be considered in some cases. The International Headache Society advises that migraine is not a contraindication for either oral contraceptive pills or menopausal hormone therapy (6,7). It is advised to prescribe the lowest effective dose of a transdermal formulation of estrogen.

3. Lifestyle modifications: Regular exercise, a healthy diet, adequate sleep, quitting smoking, and stress management can all play a role in managing both menopause symptoms and migraines.

4. Alternative therapies: Some women find relief through alternative therapies like acupuncture, yoga, CBT, hypnotherapy, neuromodulation devices, or herbal supplements. Magnesium, riboflavin, coenzyme Q10, boswellia, feverfew, and butterbur are among the supplements that have been used for migraine. Some migraine sufferers have experienced relief with the biofeedback app Juva. However, the effectiveness of these therapies can vary, and they should be discussed with a healthcare provider.

Note on Estrogen and Migraine with Aura

The International Headache Society advises that low-dose estrogen-containing contraception and menopausal hormone therapy may be prescribed in women who experience migraines (7).

However, it’s important to note that the use of estrogen should be carefully considered and monitored by a healthcare provider, as it can increase the risk of certain health issues, such as stroke. To date, transdermal formulations of estrogen (a patch, gel, or foam) have not been shown to increase the risk of a clot or stroke beyond one's baseline risk (8).

Several studies have found that migraine sufferers who take oral menopausal hormone therapy suffer from worse migraines. On the other hand, a few studies have actually shown improvement in migraines with transdermal preparations of estrogen (9). Transdermal estrogen has not been found to increase the risk of blood clot about one's baseline risk (10).

For genitourinary symptoms of menopause, there is no contraindication to try topical estrogen therapy in the genitals for women with migraines with aura.

Conclusion

Navigating menopause and managing migraines can be challenging, but with the right treatment plan, it’s possible to effectively manage both. It’s important to have open discussions with your healthcare provider about your symptoms and treatment options. Remember, everyone’s body reacts differently to medications, and what works for one person may not work for another. Always prioritize safety and informed decision-making when considering treatment options.

Please note: This blog post is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your health provider with any questions you may have regarding a medical condition.

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Sources:

1. Hutchinson, S. Use of Oral Contraceptives in Women with Migraine. Orange County Migraine & Headache Center. Accessed 2/22/2024. AHS-Fact-Sheet_Contraceptives.pdf (americanheadachesociety.org) 

2. Anne H. Calhoun, MD, FAHS and Pelin Batur, MD, FACP, NCMP. Combined hormonal contraceptives and migraine: An update on the evidence. Cleveland Clinic Journal of Medicine August 2017, 84 (8) 631-638; DOI: https://doi.org/10.3949/ccjm.84a.16033

3. Mauskop, Dr. (2020, October 24). 100 Migraine Drugs, A to Z: venlafaxine. Retrieved February 22, 2024 from 100 Migraine Drugs, A to Z: venlafaxine | Headache NewsBlog

4. Perloff, M. D., Berlin, R. K., Gillette, M., Petersile, M. J., & Kurowski, D. (2016). Gabapentin in Headache Disorders: What Is the Evidence? Pain Medicine, 17(1), 162–171. https://doi.org/10.1111/pme.12931

5. Brogden, R.N., Pinder, R.M., Sawyer, P.R. et al. Low-Dose Clonidine: A Review of its Therapeutic Efficacy in Migraine Prophylaxis. Drugs 10, 357–365 (1975). https://doi.org/10.2165/00003495-197510050-00006

6. International Headache Society. (2018). The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 38(1), 1-211.

7. International Headache Society Taskforce. Recommendations on the risk of ischaemic stroke associated with use of combined oral contraceptives and hormone replacement therapy in women with migraine. Cephalalgia 2000;20:155-6.

8. MacGregor, E. A. (2015). Migraine management during menstruation and menopause. Continuum (Minneapolis, Minn.), 21(4 Headache), 990–1003.

9. van Lohuizen, R., Paungarttner, J., Lampl, C., MaassenVanDenBrink, A., & Al-Hassany, L. (2024). Considerations for hormonal therapy in migraine patients: a critical review of current practice. Expert Review of Neurotherapeutics, 24(1), 55-75.

10. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019 Jan 9;364:k4810. doi: 10.1136/bmj.k4810. Erratum in: BMJ. 2019 Jan 15;364:l162. PMID: 30626577; PMCID: PMC6326068.