Current Treatment Options: Headache Related to Menopause—Diagnosis and Management

  • Clinton G. Lauritsen
  • Abigail L. Chua
  • Stephanie J. Nahas
Headache (JR Couch, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Headache

Abstract

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.

Recent findings

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.

Summary

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.

Keywords

Migraine Headache Menopause Estrogen Hormone replacement therapy Contraceptive 

Abbreviations

CH

cluster headache

TTH

tension-type headache

FSH

follicle-stimulating hormone

LH

luteinizing hormone

FMP

final menstrual period

VMS

vasomotor symptoms

ANM

age at natural menopause

MRM

menstrually related migraine

PMM

pure menstrual migraine

HRT

hormone replacement therapy

AMPP

American Migraine Prevalence and Prevention Study

HADS-A and HADS-D

Hospital Anxiety and Depression Scale

MIDAS

migraine disability assessment scores

SWAN

Study on Women’s Health Across the Nation

ETTH

episodic tension-type headache

MO

migraine without aura

MA

migraine with aura

MPA

medroxyprogesterone acetate

LNG-IUS

levonorgestrel-releasing intrauterine system

ERT

estrogen replacement therapy

CST

cerebral sinus thrombosis

CHC

combined hormonal contraceptive

DBPC

double-blind placebo-controlled

MRS

Menopause Rating Scale

MENQOL

Menopause-Specific Quality of Life questionnaire

EPISONO

Sao Paulo Epidemiologic Sleep Study

NAH

nocturnal awakening with headache

Notes

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

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Clinton G. Lauritsen
    • 1
  • Abigail L. Chua
    • 2
  • Stephanie J. Nahas
    • 1
  1. 1.Department of NeurologyThomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Hartford Healthcare Headache CenterWest HartfordUSA

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