Headaches and migraines in perimenopause

Why headaches get worse in perimenopause

The NHS perimenopause symptom list includes headaches and migraines that are worse than usual. Its general headaches page names "having your period or during menopause" as a cause in its own right and calls it a hormone headache.

The likely reason is the pattern of oestrogen in these years. The Migraine Trust's page on migraine and menopause explains that a drop in oestrogen is a common migraine trigger, and that levels can rise and fall quickly as menopause gets closer. It says more frequent and more severe attacks are common in perimenopause, and that some women get migraine for the first time in this stage.

Other perimenopause symptoms can add to it. The same page points out that hot flashes, night sweats and anxiety can break up sleep and raise stress, and both make an attack more likely. A run of bad nights is worth noting next to a run of bad headaches.

Menstrual migraine in your 40s

Many women who get migraine notice that attacks cluster around their period. The Migraine Trust's menstrual migraine page says up to two-thirds of women with migraine may have attacks linked to their periods. They tend to fall between two days before a period and the third day of bleeding, when oestrogen naturally drops.

The NHS migraine page says these attacks are often longer and more severe than attacks at other times. The Migraine Trust adds that nausea and sensitivity to light or sound are more likely with them, and that they can be harder to treat.

Perimenopause changes the timing. Once cycles become irregular, a migraine you could once predict from the calendar arrives without warning, and the Migraine Trust names this as one of the hard parts of these years. There is no test for menstrual migraine. A doctor confirms it from your symptoms and a diary showing attacks on period days in at least two out of three cycles.

Migraine with aura in perimenopause

An aura is a set of warning symptoms before or during an attack. The Migraine Trust's aura page lists zigzag patterns, flashing lights, blind spots, pins and needles, speech problems and dizziness. Up to a third of people with migraine get aura. It builds over about five minutes and usually fades within an hour.

Two things about aura matter more in midlife. The Migraine Trust notes that aura without any headache, which some call silent migraine, is more common in older people and in those whose migraine starts later in life. Because a stroke or an eye problem can look similar, the first time you have visual symptoms, or muscle weakness with an aura, get it seen. The NHS says to ask for an urgent GP appointment or call 111 if aura lasts longer than an hour.

Aura also matters to the people who prescribe your hormones. The Migraine Trust says the combined pill is not used by women who have migraine with aura, because of the stroke risk, so tell whoever prescribes your contraception or menopause treatment if you get it. Our page on hormonal contraception in perimenopause covers how contraception can also hide the cycle changes.

When to get a headache checked

The NHS splits headache warning signs into three levels. Use the most serious one that fits.

Call 999 or go to A&E

The NHS headaches page says to call 999 or go to A&E if you have a headache and any of these:

• it started suddenly and is extremely painful
• numbness or weakness in the face or body, or on one side
• trouble speaking, balancing, walking or remembering things
• drowsiness or confusion
• loss of vision, or blurred or double vision
• a seizure
• a very high temperature, a stiff neck, or a rash that does not fade under a glass
• a head injury in the last 3 months

The NHS also says not to drive yourself to A&E.

Urgent GP appointment or NHS 111

• a headache with vision or eye problems
• a headache brought on or made worse by coughing, sneezing, bending down or exercise
• a headache with vomiting
• a headache with jaw pain when you eat, or a sore, tender scalp
• a migraine that has lasted longer than 72 hours

Book a routine GP appointment

The NHS says to see a GP if you get headaches regularly, or if one is not easing or is getting worse. For migraine it adds attacks that are severe, getting worse or lasting longer than usual, attacks more than once a week, and regular migraine before or during your period. A change in a headache pattern you have had for years counts too, so say so at the appointment.

What to record in a headache diary

The NHS and the Migraine Trust both suggest a headache diary, and the Migraine Trust's headache diary guide keeps it to a few basics. For perimenopause, I would add the period column first, because without it the hormonal pattern cannot be seen.

• the date and day of the week
• how long each headache lasted
• how bad it was: mild, moderate or severe
• other symptoms: aura, nausea, light or sound bothering you, dizziness, numbness
• painkillers or migraine medicine taken, including a second dose
• period days, and how heavy each one was
• nights broken by night sweats or poor sleep, missed meals and other likely triggers

Counting painkiller days is worth the effort. The NHS migraine page warns that taking painkillers on more than 2 days a week can cause more headaches, a problem called medication overuse headache, and your doctor will want that number.

On paper, the printable perimenopause symptom diary on this site keeps periods and symptoms on one sheet with the same three-step scale. On a phone, Her Good Days is a free app that logs a symptom with its time and its severity next to your period dates, sleep and medicines, and makes a PDF for the dates you choose for your appointment. It records what you report and does not interpret it. The app is coming soon to the App Store and Google Play.

If periods are changing at the same time, the cycle length calculator turns your period dates into cycle lengths you can show the GP.

My take

If you have had migraine for years and it has become more frequent or now arrives around your period in your 40s, I would treat that as the common perimenopause pattern and book a routine appointment with three months of diary in hand, period days marked. That record is what lets a doctor confirm menstrual migraine and weigh options with you. I would not wait for a diary in two cases. A brand-new aura or new numbness should be seen soon. A headache that is suddenly the worst you have had, or comes with weakness, confusion or loss of vision, is a 999 call whatever your age or history.

Related reading

Headaches sit alongside the other changes in perimenopause symptoms and how to track them. If poor concentration comes with the headaches, see brain fog in perimenopause, and if heavy periods are leaving you tired, heavy periods in perimenopause explains what to check. The symptoms topic collects every symptom page on the site.