Menopause and hormone replacement therapy (HRT)
In the years leading up to a woman’s final period, the menopause, the ovaries produce diminishing amounts of oestrogen. During this time of hormonal imbalance, it is not unusual for migraine attacks to become more frequent or severe.
For the majority of women migraine settles a few years after the menopause. This is possibly because the hormonal fluctuations cease and the body adapts to stable low levels of oestrogen. A few women continue to have attacks, which can sometimes follow a cyclical pattern years after the menopause. The reason for this is not clear.
HRT replaces the oestrogen, which the ovaries stop producing after the menopause, effectively treating hot flashes, sweats and mood swings. Very few studies have assessed the effect of HRT on migraine. What has been found is that migraine is more likely to improve with the use of non-oral oestrogens such as patches or gels. Too high an oestrogen dose can trigger migraine aura, which typically resolves with a reduction in dose. Unlike synthetic contraceptive oestrogens, there is no evidence that natural oestrogens in HRT are associated with an increased the risk of stroke in women with migraine with aura.
Although progestogens are necessary unless you have had an hysterectomy, side-effects typical of pre-menstrual syndrome, including migraine, are not uncommon. Several strategies can be used to minimise this problem such as changing from cyclical to daily progestogens, if appropriate; changing to a different type of progestogen; or using natural progesterone.
Whichever type of HRT you start with, it is important to give it an adequate trial. The first three months is a time of imbalance as the body becomes accustomed to the change of hormones and if you stop too soon, you cannot reap the benefits of continued use.
If you cannot take HRT or are keen to avoid it, there is some evidence that alternative treatment such as ‘phyto-oestrogens’ which are plant oestrogens found in foods such as soya are effective. Other popular remedies include kava, red ginseng and St John’s Wort. If you do try any of these, check with your doctor to make sure they don’t interact with any other medicines you are taking.
A final word
All of us involved in treating migraine would dearly love to be able to wave a magic wand cure suffering. Unfortunately, that is not yet possible. Nevertheless, although there may not be a cure, there is a great deal that can be done to help you keep control of migraine and stop it controlling you.
