Expert Answer: Hemiplegic Migraine & Menopause: What Happens?

Unfortunately, there is no good data to predict if a female with hemiplegic migraine (temporary one-sided paralysis) will experience more or less migraines when she is menopausal. Here is what we do know: The prevalence of migraine decreases in both men and women with age. For women migraine sufferers, studies indicate that 2/3 will experience improvement of their migraines when they become menopausal. However, this 2/3 (66%) improvement is only for women who go through menopause spontaneously. If women have their ovaries removed as if often done with a hysterectomy (removal of the uterus), they fare far worse and only 1/3 will experience an improvement in their migraines with menopause. The take-home lesson here is to not rush into a complete hysterectomy unless medically necessary for reasons other than migraine headaches.

Women with menstrual migraine would be expected to notice more improvement in their migraines with menopause as they no longer have the hormonal fluctuations that are felt to be the greatest trigger for menstrual migraine. By definition, menstrual migraine is migraine without aura. However, my opinion is that women with aura including the more complicated aura called hemiplegic migraine may also have a hormonal trigger to their migraine attacks. By eliminating the ups and downs in estrogen and progesterone that characterize a women’s menstrual cycle, the hormonal trigger is removed and so I would expect less migraine attacks.

It may be useful to think about what happens during pregnancy. Estrogen levels rise, become quite high and then stay high and fairly constant until delivery. Women who have migraine without aura usually have fewer migraines during pregnancy. However, women who have migraine with aura (and hemiplegic migraine is a type of migraine with aura) often do not improve during pregnancy so for these women, the high levels of estrogen may be having a negative impact on their aura and migraines. In fact, if migraine occurs for the first time during pregnancy it is often migraine with aura.

In some sense, menopause can be considered the opposite of pregnancy since there are very low to no-existent levels of estrogen in menopausal women compared to the very high levels during pregnancy. Therefore, I predict that for most women who have migraine with aura, including hemiplegic migraine, they would experience improvement with menopause.

What would then happen if the woman with hemiplegic or migraine with aura was given exogenous estrogen in the form of an estrogen pill, patch, or cream? I think there is a chance that the estrogen treatment could negatively impact her hemiplegic migraines. Therefore, I would probably suggest alternative non-estrogen treatments for the woman with hemiplegic or migraine with aura headaches if she was symptomatic with hot flashes, night sweats, or insomnia. Options include Effexor, Gabapentin, and Prozac: all have been shown to reduce menopausal symptoms and all have shown some benefit in migraine prevention.

In conclusion, I feel that estrogen, both endogenous (from a woman’s own ovaries) and exogenous (birth control pills; hormone therapy), can be a trigger for aura and for hemiplegic migraine. Therefore, the low estrogen state of menopause could be favorable for a woman with hemiplegic migraine and I predict her migraines may improve. More research needs to be done in this area!

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