Migraines and Menopause – A Narrative Review

(Bernstein & O’Neal - Link here)

This paper looks at what happens to migraines as women move through perimenopause into menopause, why symptoms often change, and whether hormone therapy is safe for women with migraines.

Key findings

• Perimenopause often makes migraines worse.
  This is because estrogen becomes unpredictable — rising, falling, and spiking — and migraines tend to flare when estrogen swings sharply.
• After menopause, migraines may improve — but not for everyone.
  Once hormones settle into a low, stable pattern, many women experience fewer migraines. Others continue to have migraines but with different patterns or triggers.
• Migraine with aura has a small increased stroke risk.
  This is important in midlife because age, blood pressure, and lifestyle factors also start contributing to vascular risk.
• Hormone therapy is not automatically unsafe.
  The authors emphasize that menopausal hormone therapy uses much lower doses of estrogen than birth control pills.
  • Lower, steadier estrogen (especially through the skin) may actually reduce migraines triggered by hormonal instability.
  • Treatment should be individualized and chosen based on a woman’s overall stroke risk.

The take awsay is that perimenopause is a volatile time for migraines. Stable, low-dose hormones may help some women — including some with migraine with aura — as long as their vascular risk is evaluated.

Migraines in Women: A Focus on Reproductive Events and Hormonal Milestones

(Kim & Park - Link here).

This article explains how migraines change across a woman’s life: puberty, menstrual cycles, pregnancy, postpartum, birth control use, perimenopause, and menopause.

Key findings

• Female migraines are strongly hormone-driven.
  Estrogen affects several brain chemicals linked to migraine — serotonin, dopamine, glutamate, and GABA — which is why women’s migraines often follow hormonal rhythms.
• Estrogen withdrawal is a major trigger.
  Drops in estrogen (before a period, postpartum, and during perimenopause) can activate pain pathways in the brain.
• Women have a stronger response to CGRP.
  CGRP (a key migraine molecule) appears to have more powerful effects in females, which helps explain why women experience migraines more often than men.
• Perimenopause brings unpredictable symptoms.
  Because hormone levels rise and fall irregularly, many women see increased migraine attacks during this transition.
• After menopause, symptoms often stabilize.
  Post-menopause, estrogen stays low but steady, which can reduce hormonally sensitive migraine patterns.

Basically, hormones shape migraine patterns across a woman’s entire reproductive life. Estrogen fluctuations (not just low levels) are a major trigger, especially in perimenopause.

3. Menopause Hormone Therapy, Migraines, and Thromboembolism

(Khandelwal, Meeta, Tanvir - Link here).

This article focuses specifically on how menopausal hormone therapy interacts with migraine and blood-clot risk (thromboembolism).

Key findings

• Migraine itself does not automatically prohibit hormone therapy.
  Past assumptions lumped migraine into the “avoid hormones” category, but newer evidence shows that menopausal hormone therapy uses much gentler doses than contraceptives.
• Migraine with aura raises vascular risk slightly — but risk varies by age and health.
  Factors like smoking, hypertension, or obesity influence risk far more than migraine alone.
• Transdermal (through the skin) estrogen is the safest option.
  It avoids first-pass liver effects, keeps clotting risks low, and helps keep estrogen levels steadier, which may help migraine-prone women.
• Stable estrogen is better than fluctuating estrogen.
  Continuous regimens are preferred over cyclic ones because they avoid big hormonal swings that can trigger migraines.
• Progestogens matter too.
  More physiologic progesterone options (like micronized progesterone) may be better tolerated in migraine-sensitive women.

Put simply , for many women with migraines (even those with aura) the right form of menopausal hormone therapy (especially low-dose transdermal estrogen) can be safe when vascular risks are properly assessed.

Why These Three Articles?

Across all three reviews, several shared themes emerge:

1. Migraine in midlife is largely about hormonal instability.

All three papers emphasize that perimenopause, a time of irregular, unpredictable estrogen fluctuations, commonly triggers more migraines. Stability, not “higher estrogen,” is what helps.

2. Women with migraines are not automatically excluded from hormone therapy.

Both Bernstein & O’Neal and Khandelwal et al. stress that menopausal hormone therapy is very different from birth control pills. Lower doses and transdermal routes reduce clotting and stroke concerns.

3. Migraines with aura requires caution, not prohibition.

Aura increases stroke risk modestly, but total risk depends on the whole picture: smoking, blood pressure, age, metabolic factors, and the specific hormone regimen.

4. Hormones influence migraine through multiple brain systems.

Kim & Park explain the “why”: estrogen affects serotonin, dopamine, glutamate, GABA, and CGRP — all deeply involved in migraine pathways.
The other two papers reference these mechanisms when explaining why stable estrogen can help.

5. After menopause, migraines often settle down.

Once hormones become steady (even though they are low), many women experience fewer or less volatile migraine patterns. All three papers mention this.