Case study: Migraine at menopause
Dawn Marcus, MD
Linda is 53 years old and has had migraines since she was in her teens, frequently missing school because of menstrual migraines. Her migraines worsened during college to several times a month. Her doctor suggested “toughing it out” with over-the-counter pain killers and assured Linda her migraines would go away once she became pregnant. During her first pregnancy, Linda was essentially migraine free. She breastfeed for one month and about three weeks after weaning her baby, her migraines returned. She had two more pregnancies, with only mild migraine reduction during each of those pregnancies. Linda’s doctor started her on Imitrex after her last pregnancy and assured her that her migraines would go away once she hit menopause.
Linda’s menstrual periods are now very irregular and she has been having hot flashes for the last couple of months. Her gynecologist tells Linda that she’s starting menopause, however, her migraines have gotten out of control. The attacks are more frequent and severe and the Imitrex, which previously worked well, no longer helps. She even tried increasing the Imitrex dose and adding over-the-counter naproxyn, which didn’t help.
Linda is 5 feet, 7 inches tall and weighs 194 pounds. Her blood pressure was elevated to 142 over 90. Her examination is otherwise normal. Linda had been advised to do 150 minutes of aerobic exercise weekly, although she “rarely has time for exercise.”
Linda tells her doctor, “I’m afraid something must really be wrong. My migraines were supposed to go away when I made it to menopause. But now that I’m in menopause, my migraines are totally out of control.”
Menopause refers to the time in a woman’s lifecycle when she has permanently stopped having her monthly menstrual periods. Menopause does not occur on a specific day; it’s actually a long process. It is best thought of as a time of transition, beginning with the perimenopause and ending with the postmenopause. The perimenopause is a time of marked hormonal change, usually beginning 6 or more months before menopause. Hormone levels fluctuate during perimenopause, resulting in menstrual irregularities, hot flashes, sweating, and other unpleasant symptoms. Menopause is officially diagnosed after a woman has gone 1 year without a menstrual period. Postmenopause refers to any time after menopause. Interestingly, women who experience an aura with their migraines are less likely to experience improvement with menopause than those whose migraines do not involve an aura.
Menopause occurs most commonly in Westernized countries at an average age of 51, with a typical range of 45 to 55 years of age. In some countries, such as in India and the Philippines, the average age of menopause is much lower, about 44 years old. The reason for this is unclear. Women who have had a hysterectomy and are thus unable to have menstrual periods can be diagnosed as reaching menopause with a blood test that measures the level of follicle stimulating hormone or FSH, which increases during the menopause.
Ovarian function decreases as women approach their late 40s, resulting in the diminished production of estrogen, progesterone, and testosterone. Initially, production becomes more irregular, with wide and unpredictable fluctuations in sex hormone levels. These wide hormonal fluctuations can result in typical perimenopausal symptoms, such as hot flashes, mood swings, and vaginal dryness. Migraines typically worsen as hormonal levels fluctuate during the perimenopausal period, and improvement is usually delayed until women reach the postmenopausal period. After the fluctuating estrogen levels have stabilized and estrogen production drops to consistently low levels, headaches usually lessen in the majority of women and often go away for good. — pages 46-47
Like many women, Linda is experiencing a worsening of her migraines as she’s going through early menopause before reaching the postmenopausal stage when hot flashes and migraine worsening are expected to go away. While her migraines have become more frequent and severe, the location of the pain, pain characteristics, and associated symptoms have not changed. If she had developed a new type of headache or new migraine symptoms, she may have needed additional testing. For example, if she had developed an aura before her migraines that she never had before, additional testing would have been needed to make sure the change in headache pattern was not caused by something other than migraines and menopause. Except for mild high blood pressure, her physical and neurological examinations were also normal, which further supported that the change in migraine pattern was caused by a menopause effect rather than another new health problem.
Treating migraine worsening at menopause can also include therapies to help reduce non-headache symptoms of menopause, like hot flashes, mood swings, and vaginal dryness. Migraine expert Dr. Anne MacGregor published an article in the January 2012 issue of the medical journal Maturitas that focuses on the treatment of both increased migraines and other unpleasant menopause symptoms, like the hot flashes that Linda is experiencing. The first treatment for hot flashes is a change in lifestyle, including regular exercise and weight loss. Hormone replacement therapy (especially using transdermal patches or gels), antidepressants (such as fluoxetine and venlafaxine), and gabapentin can all be helpful. Standard migraine prevention therapies are also recommended to effectively decrease migraines.
You may remember the scare in 2002 when the Woman’s Health Initiative study reported increased health risks for women treated with hormone replacement therapy after menopause. Additional analysis of these data showed that the risk was higher in older women who started hormone replacement more than 10 years after starting menopause. Today, doctors often recommend a short course of hormone replacement in women who are younger than 60 years old and who have moderate or severe menopause symptoms. Linda wasn’t concerned about her hot flashes, so she opted not to start hormone replacement.
Exercise and weight reduction can also be helpful for both hot flashes and migraines. A study published in 2010 in the journal Archives of Internal Medicine showed that a 6-month structured diet and exercise program for women in menopause produced an average weight loss of seven and one-half pounds compared with only two pounds of weight lost in in a comparison group of women who received general nutrition and exercise information. In addition, the odds of hot flashes improving during this study was over twice as good among those women involved in the structured diet and exercise program. Aerobic exercise has also been shown to have a modest benefit for reducing migraines (https://migraine.com/blog/news/exercise-and-migraine/) and excess weight has consistently been linked to worsening migraines (https://migraine.com/blog/weight-and-your-migraines/).
Linda’s treatment included:
- Beginning a daily walking program, with a goal of a total of 150 minutes per week (about 30 minutes, 5 days each week).
- Linda also began a stress management and relaxation program with a pain psychologist.
- Daily preventive therapy with a beta-blocker was added to address both her high blood pressure and migraines.
Linda initially insisted that she had no time for watching her weight and exercising, insisting a busy work schedule and caring for her two children in junior high took up all of her free time. She also insisted that she’d been stressed and overweight for years while her migraines were well controlled, so these weren’t a problem for her. While stress and excess weight clearly weren’t the cause of the change in Linda’s migraines, stress management and relaxation were now used as effective migraine-relieving therapies. In addition, a review of Linda’s schedule helped determine when exercise might be feasible. Linda began walking the dog each morning for 10 minutes while her children were getting ready for school, which helped her children become more responsible for getting out of bed and ready and helped Linda begin her work day less aggravated. Linda also instituted a daily 20-minute family after-dinner walk instead of their previous time in front of the television, which helped make sure exercise was completed, reduced excess junk food snacking, and gave Linda quality time to hear about her children’s day at school.
After two months, Linda had lost 6 pounds and reported sleeping better. Her migraines were less frequent and severe, and Imitrex was once again generally effective for severe migraines that did occur. Her blood pressure had decreased to 132 over 84. After 6 months, Linda was no longer having problems with hot flashes. She had added a healthier diet to her exercise program and had lost 15 pounds. Linda was able to be weaned off the beta-blocker without an increase in either her migraines or blood pressure.