For most women, headaches are a relatively minor problem. Some women, however, experience headaches so severe their quality of life becomes greatly affected. When women reach perimenopause, hormonal fluctuations that occur can cause the onset of headaches or cause existing headache to increase in severity.

Along with the hormonal fluctuation, there are many other “triggers” that can cause migraine headaches in perimenopausal women:
  • Common foods containing tyramine such as chocolate, yogurt, sour cream, aged cheese, and red wine.
  • Preservatives found in such food as hot dogs, sausage, bacon, bologna, and smoked fish.
  • Monosodium glutamate (MSG), a flavor enhancer added to Chinese food and processed or frozen foods.
  • Any changes in eating patterns such as fasting or skipping meals.
  • Not consuming enough fluids.
  • Changes in your sleeping pattern.
  • Emotional changes such as stress, anxiety, anger, or excitement.
  • Environmental factors, such as: noise, bright lights, changing barometric pressure, inhalation of fumes.
Research studies have shown that the fluctuations of estrogen levels due to perimenopause can also increase the prevalence as well as the intensity of headaches. Women who have a history of headaches during menstruation find that during perimenopause their headaches worsen. For these women, two thirds will experience relief from their migraines after menopause.
If you are experiencing headaches, keeping a diary for a few weeks will help identify the triggers. You should keep track of the time, symptoms, and any possible contributing factor such as food, noise or stress. By identifying the pattern you can determine the best measures to take for preventing the headache from reoccurring.   Pay particular attention to the hormonal changes you may be experiencing such as menses to see if these hormonal changes affect the severity or onset of your headache.
The role of hormone therapy in headache management is unclear. Hormone replacement therapy (HT) and oral contraceptives (OC’s) have been helpful in some women with hormone-related headaches.  
  • A low-dose estrogen patch applied during the “at risk” time of a woman’s cycle may help prevent menstrual headaches. 
  • In post-menopausal women, it is best to stay on a continuous HT regimen. Different doses and regimens can be tried until the right combination is found to be the most helpful.
 If you find that estrogen replacement therapy (ERT)/HT or oral contraceptives exacerbate your migraines, discontinue use. In this case, using estradiol instead of other estrogens may be helpful. Sometimes a woman on oral contraceptives develops migraines during the placebo week. In this case a low dose estrogen patch can be used for that week.
 Use caution when prescribing OC’s or ERT/HT for women who experience migraines with aura. Studies suggest that women with aura have an increased risk of stroke, hormone therapy may add to that risk.   Progestogens may actually aggravate or precipitate headaches. If headaches are worsening with medroxy-progesterone acetate, a change to micronized progesterone may help. Continuous regimens of HT may provide greater hormonal stability than cyclic HT and therefore may reduce the incidence of headaches by smoothing out hormonal fluctuations.   A trial of weeks to months of HT may be required before improvement is seen.

Management of Headaches

Headache type



Preventative Medications

Tension headache

Steady squeezing or pressing pain on both sides of the head.

Nonprescription analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) eg, aspirin, acetaminophen, ibuprofen.

Physical therapy, stress management, relaxation therapy and biofeedback, are also helpful for some patients.

Tricyclic antidepressants or selective serotonin-reuptake inhibitors.

Migraine headaches

Moderate to severe throbbing pain worse on one side of the head. Can be accompanied by nausea, vomiting and light sensitivity.  May be aggravated by physical activity.  Lasts 4 to 72 hours.  Affects 18% of American women.

For mild to moderate pain over-the counter drugs such as aspirin, acetaminophen and caffeine combinations.

For more severe pain triptan medications such as sumatriptan (Imitrex),

zolmitriptan (Zomig),

The combination drug of isometheptene mucate, dichloralphenazone and acetaminophen (Midrin), has been found to be effective in both acute migraines and tension type/migraines.  However it may be habit-forming.

Beta-blockers, such as propanolol (Inderol); t

ricyclic antidepressants, such as amitripyline (Elavil); and

anticonvulsants, such as divalproex sodium (Depakote).

ERT/HT in perimenopausal women


Source:  NAMS (Margaret F. Moloney, RN-C, PhD, ANP) The Female Patient Vol. 27  April 2002

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