Migraine is a severe form of headache.  It is usually one-sided, throbbing, you may feel nauseated or sick and light, sound, or smells may bother you more than usual.  It usually limits your ability to work, study or do what you need to do.

You can have migraine with or without aura.  Aura is a term used to describe symptoms that you may experience before the start of your headache.  In 99% of cases, symptoms affect your vision causing dark spots, or bright zig-zag lines that shimmer or jitter as they expand across your vision. Less commonly, aura can be ‘sensory’ causing pins and needles on one side of the body with or without weakness and even speech problems.  Symptoms develop gradually over 20-30 mins, typically precede the headache, and resolve before or shortly after the onset of the headache.  Some may experience aura which is not followed by a headache.   

Migraine symptoms can worsen in the years leading up to the menopause.  This is most likely related to the fluctuations in the level of oestrogen and progesterone levels around this time.  

Hormone Replacement Therapy (HRT) should not be used as a treatment for migraine.  However, many women notice that migraine is more likely to occur when they have menopause-related symptoms such as bad hot flushes, night sweats, and poor sleep. Since HRT is very effective at controlling these menopause-related symptoms, it reasonable to predict that HRT may also help ameliorate symptoms of migraine.

Migraine or Migraine with aura is not a contraindication to the use of HRT

Patients get concerned that if they have or have had a history of migraine or migraine with aura, they can’t be prescribed HRT to control symptoms of the perimenopause or menopause. This is not the case!

It is well established that the presence of migraine with aura is known to increase the risk of stroke, especially in women, and the use of the combined oral contraceptive pill increases stroke risk even further.  Thus, women with migraine with aura are urged to avoid use of the combined oral contraceptive pills.  The combined pill is quite different to the use of HRT, which is where there may be some confusion.

The combined contraceptive pill contains high doses of synthetic oestrogen and progestogen hormones (unlike those produced by the ovary).  The high doses of hormones communicate with control centres in the brain to suppress the ovaries by telling them not to make any hormones, so you don’t ovulate (or produce an egg).  That’s how the combined pill works to stop you from getting pregnant.

In contrast, HRT is replacing the hormones oestrogen and progesterone that are naturally declining in the body around the time of the menopause.  Furthermore, HRT contains significantly less hormone than the combined pill.  So, around the time of the menopause, with HRT, we are not trying to suppress the ovary, rather, we need to restore hormone production by the ovary. 

What’s the best form of HRT to use to control menopausal symptoms in those with migraine or migraine with aura?

Some forms of HRT can create more hormone fluctuations, which can trigger migraine. This is more likely to occur with HRT tablets and with cyclical HRT.  It is generally recommended that women with migraine who need HRT should use forms of HRT that are applied to the skin (called ‘transdermal’ HRT) such as oestrogen patches, gels, or sprays, as these maintain stable hormone levels with few fluctuations. Lowering the dose of HRT may also help.  Cyclical use of progesterone can aggravate or induce migraine attacks.  The use of ‘Micronised’ Progesterone can minimise this effect, switching to a continuous combined preparation or switching to the Mirena coil which is a hormone (progestogen) releasing intrauterine device.

References: (1) Management of the Menopause: T. Hillard, K Abernathy, H Hamada, I Shaw, M Everett, J Ayres, and H Currie; 6th Edition, 2017 British Menopause Society; (2) Mechanism and Management of Headache; J. W. Lance and P. J Goadsby; 7th Edition 2005 Elsevier Butterworth Heinemann

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