Perimenopausal migraine: a narrative review

Migraine is a highly prevalent primary headache disorder that disproportionately affects women owing to the effects of sex hormones, particularly estrogen. Hyperestrogenism during early perimenopause, coupled with anovulatory cycles, is associated with an increased frequency and severity of migraine attacks and an increased prevalence of perimenstrual migraine. The natural decline in estrogen levels after menopause is generally associated with migraine improvement; however, this is variable and often complicated by chronic migraine, vasomotor symptoms, cardiovascular risk and use of menopause hormone therapy (MHT). Although there is a trend toward increasing the use of MHT during perimenopause, there are no research trials regarding migraine in this population, although it appears to have a negative clinical effect. This could be explained by the addition of MHT to the already high and fluctuating endogenous estrogen levels. More appropriate during perimenopause is hormone cycle control. This can be achieved using continuous combined hormonal contraception for women with migraine without aura, whereas progestogen-only regimens, with the option of additional transdermal estrogen, can be used in women with migraine with and without aura. For women choosing to use MHT postmenopause, continuous transdermal regimens are better tolerated than cyclical preparations.