Keywords: migraine headache headaches menopause estradiol oestradiol estrogen menopause complications medications medicine drug

Unfortunately a history of migraines during younger adult life can make menopause management difficult. Migraine is common. A recent study suggests that 17.6% of U.S. women have one or more migraines per year. There are women who have had a history of migraines which are cyclically related to their menstrual cycle. These migraines are often aggravated by estrogen. A typical history is someone whose migraines get worse when they take oral contraceptives. For many of these woman, menopause is a blessing since the migraines fade away as the estrogen levels drop. Unfortunately, dropping estrogen levels also contribute to increased risk for heart disease and osteoporosis as well as the acute symptoms of menopause. The clinical problem than is to develop a strategy to help post menopausal women with a history of migraines so that they can obtain the long term health benefit of estrogen replacement therapy.

How do we approach this problem?

First, one should certain that they truly have migraines. Other causes of chronic headaches can include sinus infections, dental problems, TMJ (temporalmandibular joint syndrome), stress and tension, depression, drug overuse (especially barbiturates which are found in Fiorinal and other medications used in the treatment of migraines, and tumors of the brain and head. There are certain warning signs that a post menopausal headache may not be a migraine but something else, perhaps more severe in nature. These warning flags include: onset in midlife, one sided headaches, persistent neurologic symptoms such as weakness, loss of sensation, confused thinking, and paralysis of eye muscles (seeing double) Lichten described a provocative test which was almost 100% predictive in determining whether a post-menopausal woman had true migraines. In this study published in Headache magazine in 1996, he reported that every women with a history of migraines would develop a headache approximately 14-18 days after an injection of estrogen while none would if they did not have a migraine history. He also concluded that post menopausal migraines occurred during periods of estrogen withdrawal and could be stabilized by continuous therapy.

Second, common triggers should be avoided if feasible. This might include the following: light, smells, dieting and hunger, loud noises, motion, travel, second hand smoke or smoking, stress, medications, caffeine, weather changes, hormone changes, and sleep disturbances.

Third, prophylaxis should reconsidered if you have more than 2 headaches/month or very severe headaches). Beta blockers such as Propranolol have been approved by FDA. A typical dose is 60-160 mg/day of the long acting form. Tricyclic antidepressants, such as imipramine (Elavil) and norpramine and the newer classes of antidepressants such as Prozac or Zoloft can also be quite helpful. Because of the close pharmacological relationship between Imitrex, Prozac, and Zoloft, caution should be used combining these agents.

Fourth, the migraine sufferer should always be prepared to break up an attack as it starts. The classic treatment for migraine which may break up the attack include ergotamine (Cafergot) . This must be taken early as possible in attack (less than 4 hours) One needs to wait several days between courses of therapy.) Common side effects include nausea. Other people use common over the counter pain killer such as Naproxen (Aleve) and Naproxen sodium (825 mg followed by 275 mg if needed) or Ibuprofen (Advil) 400-800 mg. These latter medications can irritate the stomach. For acute treatment, medications such as Fiorinal, codeine , or Naproxen or Ibuprofen can be helpful. Fiorinal contains a barbiturate. The withdrawal from this can simulate a migraine headache. A new medicine now available both in injectable, nasal spray and oral forms is Sumatriptan (Imetrex).   Some side effects include tingling, dizziness, warm/hot sensations which usually occur within minutes of injection and last less than 1 hour.

What about migraines and menopause? First, fluctuations of serum levels estrogen should be avoided. Regimens which involve fixed daily dosages--starting low and gradually building up should be considered. These should be used in conjunction with antidepressants. Some recent studies suggest that liberal use of Vitamin D and calcium may be helpful.

Drs. Caroline Dott and Andrew Dott are professional lecturers and teachers with a special interest in the interactions between the biological and psychological basis of human behavior at midlife.   Among their lecture topics are female and male menopause, the hormonal basis of human behavior, and issues related to depression and anxiety.  They are available to travel and give seminars on the topics covered in this website both nationally and internationally.