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.
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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
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Bille BS. Migraine in school children. A study of the incidence and short-term prognosis, and a clinical, psychological and electroencephalographic comparison between children with migraine and matched controls. Acta Paediatr Suppl. 1962;136:1–151.
Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: epidemiology and patterns of health care use. Neurology. 2002;58:885–94.
Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB. Migraine prevalence by age and sex in the United States: a life-span study. Cephalalgia. 2010;30:1065–72.
Facchinetti F, Neri I, Martignoni E, Fioroni L, Nappi G, Genazzani AR. The association of menstrual migraine with the premenstrual syndrome. Cephalalgia. 1993;13:422–5.
MacGregor EA. Migraine management during menstruation and menopause. Continuum (Minneap Minn). 2015;21:990–1003.
Vetvik KG, Macgregor EA, Lundqvist C, Russell MB. Prevalence of menstrual migraine: a population-based study. Cephalalgia. 2014;34:280–8.
Ekbom K, Svensson DA, Traff H, Waldenlind E. Age at onset and sex ratio in cluster headache: observations over three decades. Cephalalgia. 2002;22:94–100.
• Stillman MJ. Testosterone replacement therapy for treatment refractory cluster headache. Headache. 2006;46:925–33. Unique publication describing hormonal treatment for CH.
• Romiti A, Martelletti P, Gallo MF, Giacovazzo M. Low plasma testosterone levels in cluster headache. Cephalalgia. 1983;3:41–4. One of few publciations discussion hormonal roles in CH.
• van Vliet JA, Favier I, Helmerhorst FM, Haan J, Ferrari MD. Cluster headache in women: relation with menstruation, use of oral contraceptives, pregnancy, and menopause. J Neurol Neurosurg Psychiatry. 2006;77:690–2. One of few studies analyzes CH in women.
Rozen TD, Fishman RS. Cluster headache in the United States of America: demographics, clinical characteristics, triggers, suicidality, and personal burden. Headache. 2012;52:99–113.
Prakash S, Shah ND. Pure menstrual hemicrania continua: does it exist? A case report. Cephalalgia. 2010;30:631–3.
Maggioni F, Palmieri A, Viaro F, Mainardi F, Zanchin G. Menstrual paroxysmal hemicrania, a possible new entity? Cephalalgia. 2007;27:1085–7.
•• 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.
Ripa P, Ornello R, Degan D, et al. Migraine in menopausal women: a systematic review. Int J Womens Health. 2015;7:773–82.
Carturan P, Scorcine C, Fragoso YD. Migraine in the post-menopausal period is associated with higher levels of mood disorders, disability, and more menopausal symptoms. Arq Neuropsiquiatr. 2016;74:999–1002.
Burger H. The menopausal transition—endocrinology. J Sex Med. 2008;5:2266–73.
• Sherman S. Defining the menopausal transition. Am J Med. 2005;118, 3(Suppl 12B):–7. Important publication defining terminology of periods during menopausal transition.
Daan NM, Fauser BC. Menopause prediction and potential implications. Maturitas. 2015;82:257–65.
Honour JW. Biochemistry of the menopause. Ann Clin Biochem. 2018;55:18–33.
Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. J Clin Endocrinol Metab. 2012;97:1159–68.
Martin VT. Migraine and the menopausal transition. Neurol Sci. 2014;35(Suppl 1):65–9.
Somerville BW. The influence of progesterone and estradiol upon migraine. Headache. 1972;12:93–102.
Lichten EM, Lichten JB, Whitty A, Pieper D. The confirmation of a biochemical marker for women’s hormonal migraine: the depo-estradiol challenge test. Headache. 1996;36:367–71.
Loder E, Rizzoli P, Golub J. Hormonal management of migraine associated with menses and the menopause: a clinical review. Headache. 2007;47:329–40.
•• 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.
•• Mattsson P. Hormonal factors in migraine: a population-based study of women aged 40 to 74 years. Headache. 2003;43:27–35. This is an important population study characterizing headache patterns during the menopausal transition.
•• Wang SJ, Fuh JL, Lu SR, Juang KD, Wang PH. Migraine prevalence during menopausal transition. Headache. 2003;43:470–8. This is an important population study characterizing headache patterns during the menopausal transition.
Misakian AL, Langer RD, Bensenor IM, et al. Postmenopausal hormone therapy and migraine headache. J Womens Health (Larchmt). 2003;12:1027–36.
Martin VT, Pavlovic J, Fanning KM, Buse DC, Reed ML, Lipton RB. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016;56:292–305.
•• Hodson J, Thompson J, al-Azzawi F. Headache at menopause and in hormone replacement therapy users. Climacteric. 2000;3:119–24. This is a large study characterizing the impact of HRT on headache during menopause.
Mueller L. Predictability of exogenous hormone effect on subgroups of migraineurs. Headache. 2000;40:189–93.
• Oh K, Jung KY, Choi JY, Seo WK, Park KW. Headaches in middle-aged women during menopausal transition: a headache clinic-based study. Eur Neurol. 2012;68:79–83. Important large clinic based study characterizes menopausal headache syndromes.
Cupini LM, Matteis M, Troisi E, Calabresi P, Bernardi G, Silvestrini M. Sex-hormone-related events in migrainous females. A clinical comparative study between migraine with aura and migraine without aura. Cephalalgia. 1995;15:140–4.
• Neri I, Granella F, Nappi R, Manzoni GC, Facchinetti F, Genazzani AR. Characteristics of headache at menopause: a clinico-epidemiologic study. Maturitas. 1993;17:31–7. Important large clinic based study characterizes menopausal headache syndromes.
Terauchi M, Hiramitsu S, Akiyoshi M, et al. Associations among depression, anxiety and somatic symptoms in peri- and postmenopausal women. J Obstet Gynaecol Res. 2013;39:1007–13.
•• Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings from the Study of Women’s Health across the Nation. Obstet Gynecol Clin North Am. 2011;38:489–501. This was a large study which followed menopausal women for 10-year period of time.
Krause MS, Nakajima ST. Hormonal and nonhormonal treatment of vasomotor symptoms. Obstet Gynecol Clin North Am. 2015;42:163–79.
Gold EB, Colvin A, Avis N, et al. Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: study of women’s health across the nation. Am J Public Health. 2006;96:1226–35.
Juang KD, Wang SJ, Lu SR, Lee SJ, Fuh JL. Hot flashes are associated with psychological symptoms of anxiety and depression in peri- and post- but not premenopausal women. Maturitas. 2005;52:119–26.
• Joffe H, Hall JE, Soares CN, et al. Vasomotor symptoms are associated with depression in perimenopausal women seeking primary care. Menopause. 2002;9:392–8. One of few studies describing link between VMS and depression.
•• Tangen T, Mykletun A. Depression and anxiety through the climacteric period: an epidemiological study (HUNT-II). J Psychosom Obstet Gynaecol. 2008;29:125–31. This is an important study describing major comorbidities of the menopausal transition.
Freeman EW, Sammel MD, Liu L, Gracia CR, Nelson DB, Hollander L. Hormones and menopausal status as predictors of depression in women in transition to menopause. Arch Gen Psychiatry. 2004;61:62–70.
•• de Kruif M, Spijker AT, Molendijk ML. Depression during the perimenopause: a meta-analysis. J Affect Disord. 2016;206:174–80. This is an important study which characterizes depression the menopausal transition.
Jung SJ, Shin A, Kang D. Menarche age, menopause age and other reproductive factors in association with post-menopausal onset depression: results from Health Examinees Study (HEXA). J Affect Disord. 2015;187:127–35.
•• Nappi RE, Cagnacci A, Granella F, Piccinini F, Polatti F, Facchinetti F. Course of primary headaches during hormone replacement therapy. Maturitas. 2001;38:157–63. This is one of few studies characterizes the effect of HRT on menopausal TTH and migraine.
•• Facchinetti F, Nappi RE, Tirelli A, Polatti F, Nappi G, Sances G. Hormone supplementation differently affects migraine in postmenopausal women. Headache. 2002;42:924–9. This is one of few studies characterizes the effect of HRT on menopausal migraine.
•• Nappi RE, Sances G, Sommacal A, et al. Different effects of tibolone and low-dose EPT in the management of postmenopausal women with primary headaches. Menopause. 2006;13:818–25. This is one of few studies characterizes the effect of HRT on menopausal migraine.
MacGregor EA. Migraine, menopause and hormone replacement therapy. Post Reprod Health. 2017; 1-8
Depypere H, Inki P. The levonorgestrel-releasing intrauterine system for endometrial protection during estrogen replacement therapy: a clinical review. Climacteric. 2015;18:470–82.
• 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.
Somboonporn W, Panna S, Temtanakitpaisan T, Kaewrudee S, Soontrapa S. Effects of the levonorgestrel-releasing intrauterine system plus estrogen therapy in perimenopausal and postmenopausal women: systematic review and meta-analysis. Menopause. 2011;18:1060–6.
Wasay M, Kojan S, Dai AI, Bobustuc G, Sheikh Z. Headache in cerebral venous thrombosis: incidence, pattern and location in 200 consecutive patients. J Headache Pain. 2010;11:137–9.
Coutinho JM, Ferro JM, Canhao P, et al. Cerebral venous and sinus thrombosis in women. Stroke. 2009;40:2356–61.
•• Bath PM, Gray LJ. Association between hormone replacement therapy and subsequent stroke: a meta-analysis. BMJ. 2005;330:342. This publication highlights the association of HRT and risk of stroke.
Paciaroni MPL, Sarchielli P, Gallai V. Headache associated with acute ischemic stroke. J Headache Pain. 2001;2(1):25–9. https://doi.org/10.1007/s101940170043.
Mohammed K, Abu Dabrh AM, Benkhadra K, et al. Oral vs transdermal estrogen therapy and vascular events: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100:4012–20.
•• 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.
•• MacClellan LR, Giles W, Cole J, et al. Probable migraine with visual aura and risk of ischemic stroke: the stroke prevention in young women study. Stroke. 2007;38:2438–45. Important publication discussing the risk of stroke with visual aura.
Kemmeren JM, Tanis BC, van den Bosch MA, et al. Risk of Arterial Thrombosis in Relation to Oral Contraceptives (RATIO) study: oral contraceptives and the risk of ischemic stroke. Stroke. 2002;33:1202–8.
Bulletins-Gynecology ACoP. ACOG Practice Bulletin. The use of hormonal contraception in women with coexisting medical conditions. Number 18, July 2000. Int J Gynaecol Obstet. 2001;75:93–106.
• 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.
MacGregor EA. Contraception and headache. Headache. 2013;53:247–76.
Calhoun AH. Hormonal contraceptives and migraine with aura—is there still a risk? Headache. 2017;57:184–93.
Sheikh HU, Pavlovic J, Loder E and Burch R. Risk of Stroke Associated With Use of Estrogen Containing Contraceptives in Women With Migraine: A Systematic Review. Headache. 2018; 58: 5-21.
•• 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.
Ozyalcin SN, Talu GK, Kiziltan E, Yucel B, Ertas M, Disci R. The efficacy and safety of venlafaxine in the prophylaxis of migraine. Headache. 2005;45:144–52.
• 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.
•• Butt DA, Lock M, Lewis JE, Ross S, Moineddin R. Gabapentin for the treatment of menopausal hot flashes: a randomized controlled trial. Menopause. 2008;15:310–8. One of few publications studying nonhormonal treatment for menopausal symptoms.
Di Trapani G, Mei D, Marra C, Mazza S, Capuano A. Gabapentin in the prophylaxis of migraine: a double-blind randomized placebo-controlled study. Clin Ter. 2000;151:145–8.
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.
• Park HJ, Lee ST, Shim JY, et al. The effect of paroxetine on the reduction of migraine frequency is independent of its anxiolytic effect. J Clin Neurol. 2006;2:246–51. Important study reporting medication anti-migraine preventive efficacy.
Foster CA, Bafaloukos J. Paroxetine in the treatment of chronic daily headache. Headache. 1994;34:587–9.
•• Orleans RJ, Li L, Kim MJ, et al. FDA approval of paroxetine for menopausal hot flushes. N Engl J Med. 2014;370:1777–9. Publication describing only FDA approved treatment for menopausal hot flashes.
•• Freeman EW, Guthrie KA, Caan B, et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA. 2011;305:267–74. One of few publications studying nonhormonal treatment for menopausal symptoms.
• 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.
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.
Handley AP, Williams M. The efficacy and tolerability of SSRI/SNRIs in the treatment of vasomotor symptoms in menopausal women: a systematic review. J Am Assoc Nurse Pract. 2015;27:54–61.
•• 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.
• Da Silva AN. Acupuncture for migraine prevention. Headache. 2015;55:470–3. Important study reporting non-medication anti-migraine preventive efficacy.
Foroughipour M, Golchian AR, Kalhor M, Akhlaghi S, Farzadfard MT, Azizi H. A sham-controlled trial of acupuncture as an adjunct in migraine prophylaxis. Acupunct Med. 2014;32:12–6.
•• Reed SD, Guthrie KA, Newton KM, et al. Menopausal quality of life: RCT of yoga, exercise, and omega-3 supplements. Am J Obstet Gynecol. 2014;210:244 e1–11. One of few publications studying alternative treatment for menopausal symptoms.
• John PJ, Sharma N, Sharma CM, Kankane A. Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial. Headache. 2007;47:654–61. Important study reporting medication anti-migraine preventive efficacy.
•• Daley AJ, Stokes-Lampard HJ, Macarthur C. Exercise to reduce vasomotor and other menopausal symptoms: a review. Maturitas. 2009;63:176–80. One of few publications studying alternative treatment for menopausal symptoms.
Busch V, Gaul C. Exercise in migraine therapy—is there any evidence for efficacy? A critical review. Headache. 2008;48:890–9.
Darabaneanu S, Overath CH, Rubin D, et al. Aerobic exercise as a therapy option for migraine: a pilot study. Int J Sports Med. 2011;32:455–60.
•• Ziaei S, Kazemnejad A, Zareai M. The effect of vitamin E on hot flashes in menopausal women. Gynecol Obstet Invest. 2007;64:204–7. One of few publications studying alternative treatment for menopausal symptoms.
Ziaei S, Kazemnejad A, Sedighi A. The effect of vitamin E on the treatment of menstrual migraine. Med Sci Monit. 2009;15:CR16–9.
Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled trials. Ann Intern Med. 2002;137:805–13.
•• Shams T, Setia MS, Hemmings R, McCusker J, Sewitch M, Ciampi A. Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis. Altern Ther Health Med. 2010;16:36–44. One of few publications studying alternative treatment for menopausal symptoms.
Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: a meta-analysis of population-based studies. Cephalalgia. 2008;28:614–8.
Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology. 2002;58:354–61.
Manzoni GC, Taga A, Russo M, Torelli P. Age of onset of episodic and chronic cluster headache—a review of a large case series from a single headache centre. J Headache Pain. 2016;17:44.
Rozen TD, Niknam RM, Shechter AL, Young WB, Silberstein SD. Cluster headache in women: clinical characteristics and comparison with cluster headache in men. J Neurol Neurosurg Psychiatry. 2001;70:613–7.
Rozen TD, Fishman RS. Female cluster headache in the United States of America: what are the gender differences? Results from the United States Cluster Headache Survey. J Neurol Sci. 2012;317:17–28.
Lucchesi LM, Hachul H, Yagihara F, Santos-Silva R, Tufik S, Bittencourt L. Does menopause influence nocturnal awakening with headache? Climacteric. 2013;16:362–8.
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The authors declare that they have no conflict of interest.
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Lauritsen, C.G., Chua, A.L. & Nahas, S.J. Current Treatment Options: Headache Related to Menopause—Diagnosis and Management. Curr Treat Options Neurol 20, 7 (2018). https://doi.org/10.1007/s11940-018-0492-7
- Hormone replacement therapy