Review article| Volume 142, P24-30, December 2020

Menstrual and perimenopausal migraine: A narrative review


      • During the reproductive years menstrual migraine affects around 4–8% of all women and around 20–25% of women with migraine.
      • Migraine frequency and severity increase during perimenopause, particularly in women with menstrual migraine.
      • Perimenstrual estrogen ‘withdrawal’ is implicated in the pathophysiology of menstrual migraine, with increased prevalence of migraine in perimenopause associated with unpredictable estrogen fluctuations.
      • Symptomatic treatment of migraine is the same irrespective of whether or not attacks are associated with menstruation, and national or international guidelines should be followed.
      • Choice of preventive treatment depends on regularity of menstruation, presence or absence of menstrual disorders, presence or absence of vasomotor symptoms, sleep disturbance or depression, need for contraception, as well as a woman’s personal preferences.
      • Women needing contraception may benefit from continuous hormonal contraception. In women with migraine considering menopausal hormone therapy, transdermal estrogen together with progesterone is preferred. If hormone therapy is contraindicated, non-hormonal medication and lifestyle changes can benefit both conditions.
      • After menopause, the prevalence of migraine without aura declines with increasing time from the last menstrual period.


      Migraine is affected by the changing hormone environment, with perimenopause associated with increased migraine, particularly menstrual migraine. Menstrual attacks are recognised to be more disabling and less responsive to treatment compared with non-menstrual attacks. Perimenstrual estrogen ‘withdrawal’ is implicated in the pathophysiology of menstrual migraine, with increased prevalence of migraine in perimenopause associated with unpredictable estrogen fluctuations. Perimenopausal women often have contraceptive needs as well as menopause symptoms and it is important to understand the potential effects of exogenous hormones on migraine. Maintaining stable estrogen levels with exogenous hormones can benefit migraine but clinical trial data are limited. This short narrative review addresses the diagnosis and management of menstrual migraine in perimenopausal women, and discusses the management of menopause symptoms in peri- and postmenopausal women with migraine.


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