Intro: Migraine is a primary headache disorder generally associated with nausea and or light and sound sensitivity and auras.
Understanding how menopause impacts various aspects of health is crucial for creating a supportive workplace.
This podcast episode, brought to you by the European Menopause and Andropause Society (EMAS), features Prof Petra Stute exploring how migraines, often accompanied by nausea, light sensitivity, and auras, are influenced by menopause. Let’s dive into today’s discussion.
Prof Petra Stute: Hello everyone. My name is Professor Petra Stute and I’m the Head of Gynaecological Endocrinology and the Menopause Centre at the Inselspital in Bern, Switzerland.
It’s a great pleasure to give you some insights into the topic of menopause and migraine. I will first start with the definition and prevalence of migraine, as well as the risks associated with migraine.
Migraine is a prevalent neurovascular disorder characterised by recurrent moderate to severe headache attacks with an estimated global prevalence of 15%. The World Health Organisation ranks migraine as the second highest cause of disability in the world, especially in women under the age of 50. This makes migraine also a relevant topic in the world of work.
Migraine, especially with aura, is associated with an increased risk of stroke and other major cardiovascular events. The elevated risk of stroke in people suffering from migraine is even further increased by the use of certain hormonal treatments, especially estrogen-containing prescriptions.
But what happens to women with migraine during the menopausal transition?
Although most women with migraine develop the disorder in their teens or 20s, 8% to 13% of women with migraine report the new onset of migraine during perimenopause. The few available epidemiological studies suggest that the increase in frequency and severity of migraine attacks in perimenopause are due to perimenopausal hormonal fluctuations. The limited data available suggests that more frequent estrogen withdrawal in perimenopause is the primary driver of increased headache frequency during the menopausal transition.
In addition, the worsening of migraine in perimenopause may be due to increases in other conditions that are comorbid with migraine. Midlife women are at increased risk of anxiety, depression and sleep disturbances which are known to interact with migraine in synergistic ways. Stress in particular has a well-recognised and complex association with migraine.
Further, in cross-sectional studies, vasomotor symptoms have been reported to be more common among women with migraine. The SWAN (Study of Women’s Health Across the Nation) study found that a history of migraine predicted a higher frequency of hot flashes and night sweats. The prevalence of migraine declines after menopause with stabilisation and lowering of endogenous estrogen levels. However, the postmenopausal course of migraine depends on whether menopause is natural or surgically induced. While migraine improves in the majority of women following natural menopause, it worsens in about 70% of women with surgical menopause.
So how does the treatment of migraine during the menopausal transition look like?
Well, the treatment of migraine in any phase of life may be acute or preventive, so the majority of standard migraine treatments are indicated in women regardless of the reproductive life stage. The menopausal transition and comorbid disorders and symptoms may impact the choice of treatment.
Similarly, preventive options for peri and postmenopausal women do not require special consideration as most migraine preventive agents can be used.
But what about menopausal hormone therapy (MHT) in peri and postmenopausal women?
Various hormone therapies have been used in the treatment of migraine during perimenopause in order to mitigate fluctuating estrogen levels. On the contrary, exogenous estrogen has also been observed to trigger aura “de novo” or worsen the severity and frequency of pre-existing attacks in women who have migraine with aura. Thus, it’s important to distinguish between migraine with and without aura and also to carefully select the estrogen and progesterone component in MHT in peri and postmenopausal women with migraine suffering from, for example, vasomotor symptoms.
Several studies have shown that oral estrogen [INAUDIBLE] migraine in postmenopausal women.
The transdermal application appears to have a lower risk of complications by maintaining near physiological estradiol levels compared to oral intake, which is normally in higher doses. Thus, transdermal estrogens should be chosen, which is also associated with a lower cardiovascular risk. Furthermore, estrogen dose is important as a case series of women receiving MHT showed that higher doses of estrogen can trigger migraine aura. After reducing the estrogen doses, the aura symptoms disappeared. Thus, low-dose or ultra-low-dose estrogen should be chosen. Tibolone, an oral synthetic progesterone that is metabolised into estrogenic, progestogenic and androgenic metabolites, has also shown promising effects in primary headaches in postmenopausal women. Especially in women during the menopausal transition, the off-label combination of a transdermal estrogen with a progestin-only pill or levonorgestrel intrauterine system may be a treatment option. The progestin-only pill is used continuously which leads to the suppression of ovulation and smoothing of hormonal fluctuations. The levonorgestrel intrauterine system appears to be a good alternative to the standard MHT. It can be either used as a safe way of contraception in fertile women but also as a part of end menopausal hormone therapy providing endometrial protection, while the dose of transdermal oestrogen can be adjusted according to the vasomotor symptoms in perimenopausal women.
Now, I come to the conclusion. Migraine is significantly affected by fluctuating sex hormone levels in women during menses and across the menopause transition. While migraine generally tends to improve postmenopause, perimenopause can be associated with significant worsening in frequency and symptoms, presumably due to fluctuating estrogen levels.
The burden of migraine in midlife is further impacted by the fact that perimenopause provides treatment challenges due to the loss of predictability of hormonally-related attacks and the worsening of symptoms that frequently occur. In the context of menopause in the workplace, peri and postmenopausal women, not only suffering from menopausal symptoms but also from worsening of migraine attacks should receive special attention. And with that, I thank you very much for your attention.
powered by Borlabs Cookie