Current Treatment Options: Headache Related to Menopause—Diagnosis and Management
Purpose of review
Menopause is a life-changing event in numerous ways. Many women with migraine hold hope that the transition to the climacteric state will coincide with a cessation or improvement of migraine. This assumption is based mainly on common lay perceptions as well as assertions from many in the healthcare community. Unfortunately, evidence suggests this is far from the rule. Many women turn to a general practitioner or a headache specialist for prognosis and management. A natural instinct is to manipulate the offending agent, but in some cases, this approach backfires, or the concern for adverse events outweighs the desire for a therapeutic trial, and other strategies must be pursued. Our aim was to review the frequency and type of headache syndromes associated with menopause, to review the evidence for specific treatments for headache associated with menopause, and to provide management recommendations and prognostic guidance.
We reviewed both clinic- and population-based studies assessing headache associated with menopause. Headache in menopause is less common than headache at earlier ages but can present a unique challenge. Migraine phenotype predominates, but presentations can vary or be due to secondary causes. Other headache types, such as tension-type headache (TTH) and cluster headache (CH) may also be linked to or altered by hormonal changes. There is a lack of well-defined diagnostic criteria for headache syndromes associated with menopause. Women with surgical menopause often experience a worse course of disease status than those with natural menopause. Hormonal replacement therapy (HRT) often results in worsening of migraine and carries potential for increased cardiovascular and ischemic stroke risk. Estrogen replacement therapy (ERT) in patients with migraine with aura (MA) may increase the risk of ischemic stroke; however, the effect is likely dose-dependent. Some medications used in the prophylaxis of migraine may be useful in ameliorating the vasomotor and mood effects of menopause, including venlafaxine, escitalopram, paroxetine, and gabapentin. Other non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga may also be helpful in reducing headache and/or vasomotor symptoms associated with menopause.
The frequency and type of headache associated with menopause is variable, though migraine and TTH are most common. Women may experience a worsening, an improvement, or no change in headache during the menopausal transition. Treatment may be limited by vascular risks or other medical and psychiatric factors. We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga.
If HRT is pursued, continuous (rather than cyclical) physiological doses should be used, transdermal route of administration is recommended, and the patient should be counseled on the potential for increased risk of adverse events (AEs). Concomitant use of a progestogen decreases the risk of endometrial hyperplasia with ERT. Biological mechanisms are incompletely understood, and there is a lack of consensus on how to define and classify headache in menopause. Further research to focus on pathophysiology and nuanced management is desired.
KeywordsMigraine Headache Menopause Estrogen Hormone replacement therapy Contraceptive
final menstrual period
age at natural menopause
menstrually related migraine
pure menstrual migraine
hormone replacement therapy
American Migraine Prevalence and Prevention Study
- HADS-A and HADS-D
Hospital Anxiety and Depression Scale
migraine disability assessment scores
Study on Women’s Health Across the Nation
episodic tension-type headache
migraine without aura
migraine with aura
levonorgestrel-releasing intrauterine system
estrogen replacement therapy
cerebral sinus thrombosis
combined hormonal contraceptive
Menopause Rating Scale
Menopause-Specific Quality of Life questionnaire
Sao Paulo Epidemiologic Sleep Study
nocturnal awakening with headache
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 5.MacGregor EA. Migraine management during menstruation and menopause. Continuum (Minneap Minn). 2015;21:990–1003.Google Scholar
- 14.•• Karli N, Baykan B, Ertas M, et al. Impact of sex hormonal changes on tension-type headache and migraine: a cross-sectional population-based survey in 2600 women. J Headache Pain. 2012;13:557–65. This is one of few population studies analyzing hormonal impact on primary headache disorders.CrossRefPubMedPubMedCentralGoogle Scholar
- 18.• Sherman S. Defining the menopausal transition. Am J Med. 2005;118, 3(Suppl 12B):–7. Important publication defining terminology of periods during menopausal transition.Google Scholar
- 26.•• Aegidius KL, Zwart JA, Hagen K, Schei B, Stovner LJ. Hormone replacement therapy and headache prevalence in postmenopausal women. The Head-HUNT study. Eur J Neurol. 2007;14:73–8. This is one of few population studies analyzing the impact of HRT and primary headache disorders.CrossRefPubMedGoogle Scholar
- 49.MacGregor EA. Migraine, menopause and hormone replacement therapy. Post Reprod Health. 2017; 1-8Google Scholar
- 51.• Suvanto-Luukkonen E, Malinen H, Sundstrom H, Penttinen J, Kauppila A. Endometrial morphology during hormone replacement therapy with estradiol gel combined to levonorgestrel-releasing intrauterine device or natural progesterone. Acta Obstet Gynecol Scand. 1998;77:758–63. This study highlights the superiority of the LNG-IUS to oral progetogens.Google Scholar
- 58.•• Spector JT, Kahn SR, Jones MR, Jayakumar M, Dalal D, Nazarian S. Migraine headache and ischemic stroke risk: an updated meta-analysis. Am J Med. 2010;123:612–24. This publication presents landmark data regarding the association of migraine and migraine with aura and risk of stroke.CrossRefPubMedPubMedCentralGoogle Scholar
- 62.• Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1545–88. Important guidelines regrading stroke in women.CrossRefPubMedGoogle Scholar
- 66.•• Joffe H, Guthrie KA, AZ LC, et al. Low-dose estradiol and the serotonin-norepinephrine reuptake inhibitor venlafaxine for vasomotor symptoms: a randomized clinical trial. JAMA Intern Med. 2014;174:1058–66. One of few publications studying nonhormonal treatment for menopausal symptoms.CrossRefPubMedPubMedCentralGoogle Scholar
- 68.• Bulut S, Berilgen MS, Baran A, Tekatas A, Atmaca M, Mungen B. Venlafaxine versus amitriptyline in the prophylactic treatment of migraine: randomized, double-blind, crossover study. Clin Neurol Neurosurg. 2004;107:44–8. Important study reporting medication anti-migraine preventive efficacy.CrossRefPubMedGoogle Scholar
- 71.Linde M, Mulleners WM, Chronicle EP and McCrory DC. Gabapentin or pregabalin for the prophylaxis of episodic migraine in adults. Cochrane Database Syst Rev. 2013; 6: 1-50.Google Scholar
- 76.• Tarlaci S. Escitalopram and venlafaxine for the prophylaxis of migraine headache without mood disorders. Clin Neuropharmacol. 2009;32:254–8. Important study reporting medication anti-migraine preventive efficacy.Google Scholar
- 77.Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1337–45.CrossRefPubMedPubMedCentralGoogle Scholar
- 79.•• Chiu HY, Pan CH, Shyu YK, Han BC, Tsai PS. Effects of acupuncture on menopause-related symptoms and quality of life in women in natural menopause: a meta-analysis of randomized controlled trials. Menopause. 2015;22:234–44. One of few publications studying nonmedication treatment for menopausal symptoms.CrossRefPubMedGoogle Scholar