Worsening migraine attacks are a common problem for people approaching or in menopause (when you’ve stopped having periods for 12 consecutive months). Migraine may worsen at this life stage because drops in hormone levels can trigger migraine attacks.

Migraine attacks may last longer than they did before menopause and may become more frequent. They may also be less responsive to your usual migraine treatment.

If you’re in perimenopause (the years leading up to menopause) or menopause and live with chronic migraine, you may wonder how migraine is affected by hormone replacement therapy (HRT), a common treatment for perimenopause and menopause symptoms. Can HRT help with migraine, or does it trigger more migraine attacks?

Understanding Hormone Replacement Therapy

Hormone replacement therapy (also called menopause hormone therapy) provides low doses of the hormones estrogen and progesterone, effectively replacing these hormones which were produced by the ovaries before menopause. If you’ve had a hysterectomy (surgery to remove your uterus), then you only need estrogen therapy. You don’t need progesterone.

By replacing the hormones that drop during perimenopause and menopause, HRT reduces common hormone-related symptoms like night sweats, hot flashes, and vaginal dryness. Regulating your hormones in this way might help you sleep better and can also help prevent osteopenia and osteoporosis (low bone density), which increase your risk for bone fractures.

When HRT Is Prescribed

Your doctor can tell you if HRT is an appropriate option for managing your perimenopause or menopause symptoms. Certain health conditions might prevent you from using HRT to manage menopause symptoms. These conditions include hormone-sensitive cancers (breast, endometrial), deep vein thrombosis, pulmonary embolism, stroke, heart attack, angina, liver disease, and untreated high blood pressure, among others.

If you have migraine with aura, you should avoid combined oral contraceptives (birth control pills) because they may increase your risk of stroke. In addition to preventing pregnancy, birth control pills are sometimes used to manage perimenopause symptoms. Unlike birth control pills, HRT contains a different form of estrogen and a lower dose, so the risk of stroke is much lower, making it safe for use in migraine with aura.

How HRT Affects Migraine Attacks

For some, HRT might trigger migraine attacks just as natural hormonal changes can. For others, HRT can help reduce migraine attacks by stabilizing your hormones. It can be hard to predict whether HRT will improve or worsen migraine, but several factors can influence your response:

• Hormone stability — Whether or not a migraine attack occurs in response to HRT can depend on how much it stabilizes (or further destabilizes) your hormone levels. Your doctor will prescribe HRT at the lowest possible dose to stabilize your hormone levels.
• HRT formulation — Oral HRT is more likely to trigger migraine attacks than topical forms.
• Individual response — Your genetics and health history can have some influence over how your chronic migraine responds to HRT. Some people are more sensitive to hormones than others.

It’s worth noting that some research suggests that the hormone progesterone may help prevent migraine attacks by regulating the body’s response to estrogen. In contrast, they’ve linked estrogen fluctuations to migraine attacks, specifically when estrogen drops shortly before your menstrual period. Several studies have found that estrogen can increase migraine attacks, but once again, this isn’t the case for everyone.

How To Tell if Migraine Attacks Are Linked to HRT

If you start taking HRT for perimenopause or menopause symptoms, you may not know right away if you’re experiencing more migraine attacks than usual. To find out if HRT triggers your migraine attacks, your doctor might suggest tracking your migraine attacks with a headache diary. Be sure to include other relevant details such as when your periods start (if you still have periods) and any menopausal symptoms.

Comparing HRT Types

Not all HRT for menopause is the same. There are different formulations, including tablets, skin patches, gels, and sprays. There are also cyclical and continuous HRT types, which we’ll compare here.

Continuous vs. Cyclical HRT

Continuous forms of HRT are usually recommended for those who have reached menopause, which means they no longer get menstrual periods. Continuous forms involve taking your hormone dose every day without breaks between doses.

Cyclical HRT is more often prescribed for those who are in perimenopause and still get menstrual periods. One goal of cyclical HRT is to regulate your periods — you should bleed at the end of each HRT cycle while taking this type. Taking cyclical HRT involves taking estrogen daily and combining it with progesterone for the last 10 to 14 days of your cycle.

If you have chronic migraine, you might be more sensitive to the hormone fluctuations that occur with cyclical HRT. Cyclical HRT may trigger migraine attacks during certain points of your menstrual cycle. In this case, it may be better for you to take continuous HRT even if you haven’t reached menopause yet.

HRT Formulations

Your doctor can help you decide which HRT formulation will be least likely to trigger migraine attacks. Oral tablets aren’t typically the best HRT option for people with chronic migraine. Transdermal (skin-applied) forms such as hormone patches, sprays, and gels can provide more stable hormone levels, which means they’re less likely to trigger migraine attacks than pills or tablets.

Oral forms of HRT are also more likely to worsen migraine with aura or trigger migraine auras in people who haven’t had them before. Low-dose transdermal estrogen may be the best option to reduce hot flashes in people with migraine with aura.

Your doctor might recommend a hormonal intrauterine device (IUD), which is a hormone-releasing unit placed in your uterus. This may be your best option if heavy periods trigger your migraine attacks, since hormonal IUDs can help reduce heavy menstrual bleeding.

Talk to Your Doctor

Although certain forms of HRT are generally better if you have chronic migraine, it’s always a good idea to discuss your options in detail with your doctor. No matter which type you use, your doctor will prescribe the lowest possible dose of estrogen to minimize your risk of HRT-triggered migraine headaches.

Tell your doctor if you’re taking HRT and notice more severe or more frequent migraine attacks as well as new auras or auras that last several hours. Your healthcare provider can review your current hormone dose and may change it or recommend HRT in a different form.

If you find that HRT triggers or worsens migraine attacks, your doctor can recommend nonhormonal menopause treatments for your symptoms.

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Have you noticed any changes in your chronic migraine while on HRT? Let others know in the comments below.