Prescribing HRT in women with migraine

3 minute read

Two in three perimenopausal women may not report headache, so doctors are urged to ask patients about symptoms.

A headache specialist has urged doctors to ask perimenopausal patients about headache symptoms, because migraines are often undiagnosed and poorly managed in these women.

There were also important considerations for women taking HRT, the headache and women’s health specialist Professor Anne MacGregor told the Australasian Menopause Society Congress in Cairns last month.

Migraine symptoms become more common when women reach menopause and can have severe impacts on quality of life, but few women report migraine as a symptom of menopause. Among women who attended a menopause clinic, 62% experienced headache but did not spontaneously report it, Professor MacGregor told the conference.

And among women at the clinic who experienced migraine, 79% reported very severe or substantial disability, said Professor MacGregor, from the Queen Mary University of London.

“Our research of women with migraine attending a menopause clinic suggests that women are not receiving optimal treatment for symptomatic treatment of migraine attacks,” she said.

Migraine with or without aura does not contraindicate the use of hormone replacement therapy, but transdermal HRT was preferable, Professor MacGregor said.

Hormone replacement therapy could help migraine symptoms, “but only in the context of prescribing HRT for management of vasomotor symptoms in women with migraine”, she said.

“Migraine can be worsened by changes in hormones, so providing stable hormone levels using transdermal oestrogen and ideally continuous progestogen is best.”

Professor MacGregor told the conference that if patients experienced a new-onset migraine with aura, doctors should firstly exclude transient ischemic attack and reassure the patient.

She then recommended changing the patient’s HRT to a transdermal form and prescribing the lowest effective dose of estrogen to control vasomotor symptoms, and consider non-hormonal options if aura does not resolve or increases in frequency.

Professor MacGregor told TMR there were several alternatives to HRT that may also be helpful when patients experience migraine.

“Non-hormonal options that benefit both migraine and vasomotor symptoms of menopause include losing weight if obese, exercise, cognitive behavioural therapy and prescribed medications including SSRIs and SNRIs, particularly venlafaxine.”

Professor MacGregor told the conference that migraine was a risk factor for the onset of menopause and could predict more frequent vasomotor symptoms associated with anxiety, depression and sleep disturbance.

Professor MacGregor wrote in a review in Maturitas that “perimenstrual estrogen ‘withdrawal’ is implicated in the pathophysiology of menstrual migraine, with increased prevalence of migraine in perimenopause associated with unpredictable estrogen fluctuations”.

Professor MacGregor said general practitioners should ask women about migraine symptoms, particularly sinus headache.

“Perimenopausal women should routinely be asked about symptoms suggestive of migraine – bearing in mind that the most common misdiagnosis is sinusitis – which should then be managed appropriately according to national guidelines.”

Professor MacGregor said for most women, migraine developed during their teens and 20s, became more prevalent during perimenopause and gradually improved with time after menopause. “A few women develop migraine for the first time during perimenopause,” she said.

Migraine has a global prevalence of 19% in women and 9% in men, she wrote.

“Migraine without aura is the most prevalent type, affecting 70-80% of people with migraine.

“The three best predictors for diagnosing migraine without aura are photophobia, disability and nausea: people who report two of these symptoms have an 81% probability of migraine, with the presence of three symptoms increasing the probability to 93%.”

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