Conference Coverage

Migraine and menopause: Longitudinal study shows what to expect



– What can women with migraine expect during the menopausal transition?

About 60% will experience a change in their headache pattern. And for 60% of that group, it’s a change for the worse, Yu-Chen Cheng, MD, reported at the annual meeting of the American Headache Society.

She presented a retrospective longitudinal study of 60 women with a preexisting history of migraine who were followed through the menopausal transition. All had long-term medical records available, including brain imaging results and hormonal laboratory data.

The impetus for the study was the fact that even though three-quarters of America’s estimated 38 million migraineurs are women, all of whom will eventually undergo menopause, the question of what happens to them headache-wise as they go through this process of permanent cessation of ovarian function has received little research attention.

Headache image ©Eraxion/

“This longitudinal study addresses the pattern of change of migraine during menopausal transition, an important but underestimated and undermanaged issue. We need more awareness of this. We hope in the future that physicians can pay more attention to this and provide better treatment for our patients with impaired quality of life,” said Dr. Cheng, a neurologist and postdoctoral fellow at Massachusetts General Hospital and Harvard Medical School, Boston.

Of the 35 women who experienced a change in their migraine attacks in association with menopause, the change occurred perimenopausally or postmenopausally – that is, after the final menstrual period – in 84% of cases. Premenopausal change in migraine in women who hadn’t yet missed a menstrual period in the past 12 months was a less frequent event.

No significant demographic differences existed between the 35 women with migraine change during the menopausal transition and the 25 women whose headache pattern remained stable. However, there were significant differences between the two groups in terms of the change over time in serum estradiol and follicle-stimulating hormone (FSH) levels. The median estradiol level in women whose migraine pattern remained stable went from 29 pg/mL premenopausally to 16.5 pg/mL post menopause, a statistically nonsignificant difference. In contrast, the median estradiol in women who experienced a change in migraine pattern dropped from 52.6 pg/mL premenopausally to 22.5 pg/mL post menopause, which was a significant difference.

Similarly, the pre- to postmenopause change in median FSH from 38.6 to 62.8 IU/L in the stable migraine group didn’t attain statistical significance, while the bigger shift in the migraine change group – from 13.5 IU/L premenopausally to 62.2 IU/L post menopause, was statistically significant.

“So we can say there’s a greater hormonal change in the migraine change group for women in the menopausal transition,” the neurologist said. “This suggests the possibility that a significant steep decline in estradiol level may stimulate migraine change.”

Brain imaging findings in the two groups were similar: Nearly two-thirds of women in both groups had normal brain MRI results, while the rest had nonspecific findings.

Several female headache specialists in the audience rose to thank Dr. Cheng for shining new light on a major understudied issue with far-reaching quality-of-life implications. Could hormone replacement therapy possibly prevent worsening of migraine attacks in association with menopause? she was asked.

Dr. Cheng noted that hormone replacement therapy was used by about two-thirds of women whose migraines remained stable and a similar proportion of those whose headaches changed. But the study wasn’t designed or sized to examine any possible migraine-preventive effect of hormone therapy. That would properly be addressed in a large prospective study. Anecdotally, however, it has been her clinical impression as well as that of some of her fellow neurologists at Massachusetts General that hormone replacement therapy does seem to protect against worsening migraine attacks in menopause, she added.

Dr. Cheng reported having no financial conflicts regarding her National Institutes of Health–funded study.

SOURCE: Cheng Y-C and Maleki N. Headache. 2018;58:71. Abstract OR16.

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