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The Menopause Exchange Blog

HEADACHES & MIGRAINE AT THE MENOPAUSE

It’s common to experience headaches around the menopause, but migraines in particular can increase in frequency at this time of life. Migraines occur more often in women than men. One of the reasons for this, is that there’s often an underlying hormonal trigger, with over 60% of women having migraines around the time of their period. Fourteen percent of women with migraine have menstrual migraine, which is triggered by a fall in oestrogen at the start of a period, resulting in a migraine within the first day or two.

This article was included in issue 77 (summer 2018) of The Menopause Exchange newsletter.

Identifying symptoms
A migraine is a headache occurring from time to time, lasting up to 72 hours, with a definite start and finish. Headaches that just go on and on are more likely to be a tension type headache (TTH), with muscle spasms in the scalp due to underlying tension in the neck and upper shoulders being the most common cause. Sometimes, tension type headaches blend into migraines, which can make the diagnosis difficult.

The ‘PIN’ questionnaire can help to distinguish a migraine from other types of headache. ‘P’ stands for ‘photophobia’, a dislike of bright light and ‘I’ for ‘impairment’, being unable to carry on normal activities. ‘N’ is for ‘nausea’, meaning a sufferer feels sick or vomits. If you have at least two of these three symptoms, it’s likely to be a migraine headache. The headache is typically described as ‘throbbing’ and often affects one side of your head by your temple.

Migraine with aura has flashing zig-zag lights and causes a loss in vision, usually on one side, with other symptoms such as sensitivity to sound, difficulty thinking straight, problems with speaking and pins and needles or numbness in your face or hands. In severe cases, the aura includes a weakness or paralysis of an arm or leg (‘hemiplegic migraine’). The aura starts before the migraine, lasts for up to an hour and settles before your headache begins. Often women feel unwell for a day or two before their migraine, with fatigue, irritability, food cravings and blurred vision or spots before their eyes, but these aren’t aura symptoms and are experienced by all migraine sufferers.

Migraine triggers
Non-hormonal triggers for migraine include stress, or relaxation after times of stress, anxiety and depression, diet (cheese, chocolate, alcohol, citrus fruits), missed meals or drinks, sleep deprivation or excessive sleep and medication, such as the combined oral contraceptive pill. There’s often a family history of migraine with one or both of your parents having migraine themselves.

Trying to stay relaxed, watching your diet and avoiding long periods staring at a computer screen can help to reduce migraine attacks. Regular eye tests to check whether you need glasses will also help, as some migraines are triggered by an imbalance in vision (astigmatism).

Treatment choices
When treating migraine, avoid strong (codeine-containing) painkillers, as these can make headaches worse, and may lead to an ‘analgesic headache’. Taken too often, these painkillers can cause a headache and lead to ‘chronic daily headache’. This is when you’re taking painkillers everyday to try to relieve your headache but are in fact prolonging it.

The current advice is to take a high dose anti-inflammatory tablet, such as 400mg to 600mg ibuprofen and 1g of paracetamol, as soon as you realise a migraine is starting and to lie down in a darkened room if possible. Co-codamol (codeine and paracetamol) should be avoided, other than a very low dose (once or twice a month). If you feel you need to take codeine on more than three to four times a week, speak to your GP.

Triptan medicines (e.g. sumatriptan, rizatriptan) have been shown to have the same effect. Most patients needing more than six triptan tablets a month are also likely to be having withdrawal headaches from the medicines and should consult their GP for further advice.

Migraine prevention
If your migraines are occurring regularly, your GP may prescribe prescription-only medicines that can prevent or reduce the frequency of your migraines. Medicines include amitriptyline, topiramate and pregabalin. Migraines without aura can become worse around the menopause, due to an increase in the number of periods or differing levels of oestrogen. Therefore, trying to stabilise hormone levels can be an effective treatment. Taking the combined contraceptive pill continuously or putting two or three packets one after the other may be an option, but you can’t do this once you’re over 50, due to a generalised increase in the risk of having a stroke. Contrary to popular belief, migraine doesn’t stop women with distressing hot flushes and night sweats using HRT, but tablets are usually avoided as these cause hormone fluctuations.

Before the menopause, women may be able to use an oestrogen-containing HRT patch plus a progesterone-containing coil (‘IUS’, e.g. ‘Mirena’), with the lowest strength of oestrogen that controls their symptoms. They may be able to use this after the menopause as well. Other HRT combinations for migraine sufferers after the menopause include combined continuous oestrogen and progesterone patches, tibolone or a continuous oestrogen patch with progesterone tablets. Migraines without aura tend to ease off after the menopause, presumably due to the much lower hormone levels, but migraines with aura unfortunately appear to be unaffected by the menopause.

‘Red flag’ symptoms
If a headache is a new symptom and you are over 50, with no previous problems with migraine, or the aura lasts for longer than an hour, causes muscular weakness or comes on very suddenly and it’s the worst headache you have ever experienced in your life, contact a healthcare professional without delay. Also seek medical advice if your normal symptoms change, a new headache lasts for days or a headache is brought on by coughing or sneezing, scalp tenderness or jaw pain. Headaches due to brain tumours are thankfully very rare but sometimes there can be other underlying serious problems in the brain that need immediate treatment.

About the author
Dr Jeni Worden is a GP with a keen interest in women’s health, particularly contraception and the menopause.  She lives and works in Christchurch, Dorset.

 Created Summer 2018

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