SAN FRANCISCO -- About 60% of women with migraine experience changing headache patterns around the menopause transition, with a majority of those reporting greater frequency or worsening intensity, according to research presented here.
Migraine changes were most likely during the post-menopausal period -- reported by 43% of study participants -- and were associated with greater changes in hormone levels.
The results were presented at the American Headache Society annual meeting.
Women make up three-quarters of all patients with migraine. Past research has shown that migraine patterns may change over the course of the normal menstrual cycle, as well as during pregnancy or after giving birth, suggesting that hormonal levels and patterns play a role. Although some prior studies have reported an increase in headaches during peri-menopause, there are few data about the changing course of headaches in women with pre-existing migraine as they go through the menopause transition.
"The evolution and character of migraine during the peri-menopause has not received as much attention as it deserves, so it's nice to see this study. The study results are consistent with the common clinical impression that the peri-menopausal transition is a time when migraine headaches often change in character," Elizabeth Loder, MD, MPH, chief of neurology at Brigham and Women's Hospital in Boston, told 鶹ý.
Yu-Chen Cheng of Massachusetts General Hospital in Boston presented findings from a retrospective study of changing migraine patterns among women of peri-menopausal and menopausal age, 40 to 60 years.
The study used data from the Research Patient Database Registry of Partners HealthCare, a not-for-profit system in the Boston area that includes a managed care organization, hospitals, community health centers, and home care.
The analysis included 60 women with data on pre-existing migraines prior to menopause who had available MRI reports and medical records with information on estradiol and follicle-stimulating hormone (FSH) levels. Most (80%) were white, the median age at menopause was approximately 47 years, and two thirds used estrogen-based hormone replacement therapy (HRT). There were no notable demographic differences between the group with migraine changes and the group without changes, Cheng said.
Of these women, 35 (58.3%) reported migraine changes while 25 (41.7%) said they did not have changes. Within the first group, 60.0% reported greater frequency or intensity, 28.6% said the characteristics of their headaches changed, and 2.8% reported both.
Migraine changes were most likely to occur post-menopause, or after the final menstrual period (42.9%). This was followed by changes during peri-menopause, defined as either clinical indications such as irregular periods or climacteric symptoms, or 1 year before the final menstrual period (31.4%). Changes were least likely to occur pre-menopause, defined as having regular periods (14.3%).
Women who experienced migraine changes experienced greater hormonal changes than those who did not. Women with migraine changes started with higher levels of estradiol before menopause (median 52.6 versus 29.0 pg/mL) and saw a larger drop, as well as having lower pre-menopause FSH levels (median 13.53 versus 38.58 U/L) and a greater rise. Most of these differences, however, did not reach statistical significance.
Brain imaging showed that a majority of women with and without migraine changes had normal MRI findings (68.6% and 56.0%, respectively). Women without migraine changes were numerically more likely to have pituitary abnormalities and white matter lesions, but again the differences were not statistically significant.
While the underlying mechanism for migraine change during menopause remains unclear, Cheng said, previous research indicates that declining estrogen levels stimulate migraine attacks in the late luteal phase, and migraineurs have a faster decrease in estrogen than women without migraine. The steep decline in estrogen may trigger migraine changes during the menopause transition, she suggested.
"This is an important but underestimated and undermanaged issue, and more awareness and better treatment are needed," Cheng and colleagues concluded.
Asked about the potential of HRT for managing migraines during the menopause transition, Cheng noted that women with and without migraine changes in this analysis had similar rates of HRT use, and said that studies have produced mixed results about whether HRT triggers migraine or is beneficial.
"It could be beneficial in the future to use hormone therapy for these patients," Cheng told 鶹ý.
Loder cautioned that the women in this study may not be representative of all peri-menopausal women with migraine.
"It is possible that some of the testing and imaging may have been done in response to changes in migraine status; thus, requiring the presence of tests and imaging in order to include patients in the study may have inadvertently selected a group in whom pituitary abnormalities or clinical worsening are more likely. Further prospective studies would be needed to verify this observation," said Loder, who was not involved in the study.
Lauren Green, DO, RD, of the Keck School of Medicine at the University of Southern California, said that brain imaging may be a useful tool for managing women with headaches during the menopause transition.
"In neurology, we are always concerned about secondary headaches versus the more common primary headache such as migraine," Green told 鶹ý. "This study supports performing MRI imaging on peri-menopausal and menopausal women with a distinctive change in their typical headache presentation."
Disclosures
Cheng, Loder, and Green made no relevant disclosures.
Primary Source
American Headache Society
Cheng Y-C, et al "Migraine pattern changes in women during the menopause transition" AHS 2018; Abstract OR16.