Mrs Smith was a 48 year old lady who presented with worsening migraines. She had a long history of migraines, usually with visual aura, and the frequency of these had increased during the last few months.
She was taking time off work as a result of the migraines, and although she was taking zolmitriptan for the headaches, she was concerned about the frequency of her migraines. She would experience as many as three to four a week. She was working as a lawyer and although her job was demanding, the intensity of her work had not changed recently. Her diet was healthy, she did not drink caffeine and only drank alcohol occasionally.
Mrs Smith had been a frequent attender to the practice over the past year. She initially presented with a short history of anxiety and palpitations which had no obvious triggers. She had been referred to a cardiologist and no underlying cause had been determined.
Mrs Smith had seen a different doctor with symptoms of increased urinary frequency and some occasional stress incontinence. She had subsequently been reviewed by a urologist and all investigations were normal at that time.
Mrs Smith was otherwise very well. Other than her migraines, she had no past medical history of note and was not taking any regular medication. She had a Mirena coil inserted two years ago for contraception and was not having any periods.
On direct questioning Mrs Smith said that had been feeling more tired than usual over the past six months or so. She was also finding her concentration worse than it used to be and she was experiencing episodes of unexplained anxiety and occasional spells of crying for no reason.
She did not have any night sweats but did admit that she felt warmer than she used to, especially in the mornings. Her libido had reduced somewhat but she had not spoken to anyone about this. She was experiencing some vaginal dryness so sexual intercourse was also more difficult as it was often uncomfortable and painful.
The patient’s symptoms were related to her menopause or perimenopause. As she was not having periods due to her Mirena coil, it was not possible to determine what stage of the menopause she was at. Oestrogen was recommended for both menopausal and migraine symptoms. A prescription of twice daily Oestrogel was arranged, with a review at three months.
At three months, Mrs Smith was feeling remarkably better; her migraines had dramatically reduced in frequency and her other symptoms had also improved. Her vaginal dryness had already improved and she had not noticed any more palpitations. Interestingly, her urinary symptoms had also improved. She was absolutely delighted to be feeling better and continued on this treatment.
It is well recognised that the perimenopause can be associated with an increased prevalence of migraine.1 Worsening of migraine intensity and frequency can be influenced by hormonal factors, particularly by oestrogen levels, which are lower in the perimenopause period.2
Although the majority of women and healthcare professionals treating them do not consider migraine as a component of the climacteric syndrome, many women do experience migraine during perimenopause. A careful history needs to be taken in a woman presenting with migraine for the first time. If a woman already suffers from migraine, the attacks often worsen during menopausal transition.3
Hormone replacement therapy (HRT) can be beneficial in these women and can help to improve both the severity and frequency of migraines. There is an increased risk of stroke in women with migraine with aura which needs to be taken into consideration.4
However, the risk of stroke associated with HRT is lower with the use of transdermal oestrogen over oral preparations.5 This is consistent with the finding of lower VTE risk with transdermal preparations. This is because transdermal oestrogens bypass first pass metabolism, resulting in no activation of clotting factors.
Women who have perimenopausal symptoms or menopausal symptoms should be considered for transdermal oestrogen preparations when prescribing HRT. For the majority of women under the age of 60 years, the benefits of HRT outweigh the risks and women should be informed of this.
- Dr Louise Newson is a GP in the West Midlands
- Martin VT, Pavlovic J, Fanning KM et al. Perimenopause and Menopause Are Associated With High Frequency Headache in Women With Migraine: Results of the American Migraine Prevalence and Prevention Study. Headache. 2016 Feb;56(2):292-305
- Ripa P, Ornello R, Degan D et al. Migraine in menopausal women: a systematic review. Int J Womens Health. 2015 Aug 20;7:773-82.
- Allais G, Chiarle G, Bergandi F et al. Migraine in perimenopausal women. Neurol Sci. 2015 May; 36 Suppl 1:79-83.
- Ibrahimi K, Couturier EG, MaassenVanDenBrink A. Migraine and perimenopause. Maturitas. 2014 Aug;78(4):277-80
- NICE. Menopause: diagnosis and management. NG23. November 2015. [Accessed 3 May 2017]