Dr. Patricia Yarberry Allen is a collaborative physician. She believes in consulting with the best medical minds on issues that require specialization or unique clinical experience. Today, Dr. Pat calls on the expertise of neurologist Joseph Safdieh. A patient desperate for relief from severe menopausal symptoms has been advised not to take hormone therapy because she suffers from frequent migraines.

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Dear Dr. Pat:

I am 50 years old, and my last period was 11 months ago. I am having severe menopausal symptoms. I am sweating during the day and at night. Forget sleep. I have two glasses of wine—to decrease my edginess and improve my rotten mood—with dinner, which is often late. I fall asleep exhausted; then I wake up many times during the night, throwing the covers off, and sometimes having to change the sheets. My husband has moved into another bedroom because he said he didn’t have to go through menopause too! Needless to say I have no interest in sex.

I wake up exhausted. It is like this, day in and day out. I am otherwise fit and healthy, except for migraines, which I have had since I was a teenager. I have three to four headaches a week and have been given Imitrex to take to prevent the headaches, but it only works about 50 percent of the time; then I resort to Tylenol with codeine and have to sleep the headache off. I don’t have any visual change before the migraines, the way my sister has. My family is healthy and no one has died young except my mother’s sister, who had a stroke about my age. She was healthy and not overweight, didn’t smoke and no one ever knew why she had a stroke.

I saw my gynecologist because I really need hormone therapy to manage these symptoms. I had a normal mammogram and physical and pelvic exam. I know that there are risks with these drugs, but I won’t have a marriage or a job if I don’t feel better soon. My gynecologist told me that I could not take hormones because of my migraines.  She said that people with frequent migraines have more strokes and that my aunt’s early-age stroke also increases my risk. Is this really true? What else can I do?

My memory is off, my mood is off, and my thermometer is off. I really need help.

Paula

Dr. Pat Responds:

Dear Paula:

You certainly have some really unpleasant symptoms that are interfering in the quality of your life, your marriage and your work life. I can tell that you are motivated to feel better. First of all, do have blood tests for thyroid function and a fatigue workup. If these blood tests are normal, then you may be right in your surmise that your symptoms are largely due to the impact of hormonal change.

But, Paula, you need to do your part to change some behaviors in order to improve your symptoms. Stop drinking for two months. Alcohol consumption causes increase in headaches/migraines, worsens mood disorders, and causes sleep disturbance. Don’t eat late. Avoid overreacting when you have night sweats.  Seriously—take a meditation class. It can be very helpful to breathe calmly when you are awakened by flushes and sweats instead of panicking and increasing the severity of these events.

I have asked Dr. Joseph Safdieh, Medical Director of the Neurology Clinic at Manhattan’s Weill Cornell–Presbyterian Hospital, to discuss this not-uncommon problem: Can a truly symptomatic patient use systemic hormone therapy for the control of symptoms in the lowest effective does when she has frequent and severe migraines?

Dr. Pat

Dr. Safdieh Responds:

Dear Paula:

Migraine headache is a common condition among women. For most patients, migraine begins in adolescence or young adulthood and persists throughout life. Migraine, by definition, is an episodic disorder, and it can often be quite difficult to predict when a headache will occur. That said, there are a number of common triggers that may be associated with the development of headaches in patients with migraine. The most consistently agreed upon triggers include lack of sleep, stress, skipping meals, and hormonal changes.

Hormone changes occur predictably during the natural menstrual cycle of women, and therefore many women with migraines know that the time around their menstrual period may be associated with the development of a migraine headache. Women who have migraines only around their menstrual period and at no other time have a condition called “pure menstrual migraine.” This is not as common as the more typical migraineur; she will have headaches at the time of her menstrual period, but also at other times of the month. This pattern is known as “menstrually related migraine.”

The migraine headache during menstruation is believed to be provoked by abrupt drops in estrogen levels. The majority of women with migraines will actually have a reduction in their headaches during pregnancy, due to the lack of estrogen drops at that time. 

Unfortunately, menopause with migraines is a very different situation, and can be much more unpredictable. During menopause, estrogen levels may fluctuate unpredictably and with no specific pattern in time, and this leads to an erratic, unpredictable migraine pattern. As in your case, it is often during menopause that women with migraines come to medical attention, as they may develop an increase in headache frequency, intensity and duration.

There are number of effective strategies to tackle migraines during menopause. Your case is particularly challenging because you are suffering with four migraines per week. Anyone with migraines who experiences more than 15 headaches per month is considered to have chronic migraine. Treating chronic migraine cannot be done by treating each individual headache alone. I certainly would not recommend use of Tylenol with codeine, since codeine, like all narcotics, can drastically increase the frequency of headaches due to rebound effect.

In your case, I would suggest that you ask your doctor about preventative medications. They really can work quite well! There are a number of FDA-approved medications that can be used daily and that help prevent migraine headaches, often by 60 percent or more. I usually do not recommend hormonal therapy for menopausal migraines, since have found that the effect on headaches is quite variable, and sometimes can make them worse. In terms of treating individual headaches, if sumatriptan (Imitrex) is working only variably, I would make sure that it is being taken within the first one to two hours of development of the headache. Sumatriptan tends to work better when combined with naproxen (Aleve). There are other “triptans” that are cousins of sumatriptan that may be even more effective for you.

To answer your last question, migraine without aura (usually, visual changes before a headache) is not associated with any increased risk of stroke at all. So there is no need to be worried in that regard. Only migraine with aura, the kind your sister has, increases the risk of stroke, and only minimally at that.

Although the risk of stroke is “doubled” in migraine with aura, the baseline incidence is so low that the risk of a stroke is still quite small. That said, if someone has migraine with aura, caution should be advised regarding other behaviors that increase stroke risk, such as smoking and excessive alcohol intake. 

In postmenopausal women, hormone replacement therapy may increase the risk of stroke, but the overall risk is still quite low, and the decision should be individualized for each patient after a discussion with her doctor. I generally recommend that if my patient would like to use HRT, she consider a skin patch version, as opposed to an oral version, since  skin patch HRT has not been associated with higher stroke risk.