Migraine and hormones: periods, contraception, pregnancy and menopause

Migraine is common, with the NHS video on its page stating that migraines affect 10 million people in the UK. The NHS says women are more likely to get it than men, and that you are more likely to get it if a close family member has it. Many women notice that their attacks change at times of hormonal change.

The sources used here do not set out the biological mechanism by which hormones influence migraine, so this page does not attempt to explain it. What they do describe is the pattern: attacks linked to periods, a possible improvement in pregnancy, improvement after the menopause, and safety points about hormone-containing medicines.

The NHS describes migraine attacks that happen just before or during your period as menstrual migraines, often longer and more severe than attacks at other times. NICE says to suspect menstrual-related migraine if migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive cycles, confirmed with a diary over at least 2 cycles.

For predictable menstrual-related migraine that does not respond adequately to standard acute treatment, NICE says to consider frovatriptan or zolmitriptan on the days migraine is expected. The NHS says to see a GP if you regularly get migraine before or during your period.

The key safety point concerns aura. NICE says combined hormonal contraceptives should not be routinely offered for contraception to women and girls who have migraine with aura. Aura, as the NHS describes it, is a warning sign such as seeing zigzag lines or flashing lights, numbness or tingling, feeling dizzy or difficulty speaking, lasting no longer than 1 hour.

Anyone who gets aura symptoms, or whose migraine changes after starting a hormonal contraceptive, should talk to a GP or nurse promptly. The NHS says to ask for an urgent GP appointment or call NHS 111 if aura symptoms last longer than 1 hour at a time. Other contraceptive options exist, and the clinic can help match the method to the person.

The NHS says migraine sometimes improves in pregnancy. It also says to ask for an urgent GP appointment or get help from NHS 111 if you have a migraine attack and you are pregnant or have just had a baby.

NICE says to offer paracetamol for acute treatment of migraine during pregnancy, and to consider a triptan or an NSAID after discussing the need for treatment and the risks of each medicine in pregnancy. It says topiramate should not be used for migraine prevention in pregnancy, or in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled, and that specialist advice should be sought if preventive treatment is needed during pregnancy.

The NHS says that in women migraine often gets better after the menopause. The years leading up to it can be less predictable, and the NHS menopause page lists headaches and migraines that are worse than usual among the other ways the menopause and perimenopause may affect you.

A headache diary is useful through this phase. Anyone with new or changed headaches, or aura, around the menopause should see a GP rather than assuming it is hormonal, particularly if any of the NHS emergency features are present.

The NHS says migraine cannot be cured, but treatment can help manage the symptoms of an attack and prevent attacks. Acute treatment includes painkillers such as ibuprofen and paracetamol, triptans and gepants, and medicines that stop you feeling or being sick. Prevention includes beta blockers, antidepressants and medicines for epilepsy, acupuncture, relaxation techniques, CBT and vitamin B2, with lifestyle changes such as eating at regular times and drinking less caffeine.

NICE advises considering propranolol, topiramate or amitriptyline for migraine prevention after a full discussion of the benefits, risks and suitability of each, taking into account factors such as depression and pregnancy.

The NHS says to call 999 for a sudden extremely painful headache, problems speaking or remembering things, loss of vision or blurred or double vision, drowsiness or confusion, a seizure, a very high temperature with symptoms of meningitis, weakness on one side of the body or face, or a recent head injury.

It says to ask for an urgent GP appointment or call NHS 111 if an attack has lasted longer than 72 hours, aura lasts longer than 1 hour at a time, or you are pregnant or just had a baby.

A GP is the usual first point for reviewing a migraine pattern, contraception and treatment, and can refer to a specialist if treatments are not working. NICE's guideline applies to NHS care.

Private headache clinics and gynaecology services are available for those who want quicker access, but the key questions remain the same: what pattern is the diary showing, is there aura, and which hormone-containing medicines are being used.