Megan Donnelly, DO, is a neurologist specializing in headache medicine and obstetric neurology. Claire Bowles, MD, is a gynecologist who takes an individualized, holistic approach to care. While their practice areas are different, they have one thing in common: They both see women for migraines due to perimenopause and menopause.

Hormonal changes during menopause can worsen existing migraines or lead women to experience them for the first time. In this Q&A, Dr. Donnelly and Dr. Bowles share joint insights on migraine management during perimenopause and menopause, reflecting the overlap between these areas of care.

Why do migraines often worsen or change during perimenopause and menopause?

Fluctuating estrogen is the main driver of migraine changes during perimenopause. As estrogen levels rise and fall unpredictably, these hormonal shifts can increase the brain’s sensitivity to migraine, making attacks more frequent, more severe and less predictable.

At the same time, perimenopausal symptoms such as hot flashes, poor sleep, and worsening anxiety or depression can further lower the threshold for migraine, adding to symptom burden.

Do migraines improve after menopause?

Yes, many women will find that once hormone levels stabilize after menopause, migraines will improve. However, this improvement is not universal.

After natural menopause, hormonally sensitive migraines (such as menstrual migraine) frequently improve due to stable low estrogen. However, persistence is common, especially in those with chronic migraine, comorbidities or surgical menopause.

What should be evaluated in primary care before attributing worsening migraine to perimenopause/menopause?

Hormonal changes are a common driver of migraines in midlife, but a careful evaluation by a primary care provider is also important. Problems with sleep, blood pressure, blood glucose fluctuations and other medical conditions can also play a role.

Here is a list of secondary or modifiable contributors to rule out first:

●Medication overuse headache

●Sleep disorders, especially insomnia and obstructive sleep apnea

●Mood disorders like anxiety and depression

●Thyroid disease

●Anemia

●SNOOP10 features

●Changes in aura pattern, which can be a sign of vascular risk

Should primary care order hormone labs (FSH/estradiol) to confirm perimenopause in patients with migraines?

No, not routinely. Perimenopause is typically a clinical diagnosis, based on age, symptoms and menstrual cycle changes. Hormone levels fluctuate significantly day to day during this time, so a single lab value can be misleading and does not reliably confirm or exclude perimenopause. In fact, we can often move forward with treatment based on symptoms alone, without relying on labs.

What first-line migraine treatments are most effective during perimenopause and menopause?

Migraine treatment in midlife isn’t completely different, but the focus shifts. We’re continuing to use medications we know are effective, like triptans, while using newer target therapies when indicated. However, we also pay much closer attention to trying to stabilize hormonal shifts. Here is a list of current medications used to treat migraines during perimenopause and menopause:

●Acute: Triptans, NSAIDs and gepants.

●Preventive: CGRP monoclonal antibodies and gepant preventives.

●Mini-prevention: For patients who are still having menstrual cycles, and whose migraine patterns are linked to their cycles, perimenstrual triptan and NSAID strategies are first-line treatments.

We also focus on improving sleep, stress management and lifestyle factors that may be contributing to migraines. Often, it is a combination of effective medication and lifestyle management that can make the biggest difference in a patient.

How do menopausal hormone therapy (MHT) and hormonal contraception affect migraine?

Hormones can either help or worsen migraines, and the difference often comes down to stability. We typically favor transdermal estrogen and take a “start low, go slow’” approach to avoid triggering symptoms. It’s very individualized, but steady hormone delivery is usually better tolerated than fluctuating levels. Here’s a breakdown of how MHT and hormonal contraception tend to affect migraine.

●MHT: Transdermal estrogen (steady dosing) is preferred and may improve migraines. However, MHT worsens migraine in some. This is more likely to be the case in migraine with aura.

●Oral estrogen: There is more hormonal fluctuation with oral estrogen, which can worsen migraine. It also carries a chance of worsening triglycerides and higher vascular risk.

●Progesterone: Generally neutral. It must be included for MHT in anyone with a uterus.

●Combined hormonal contraception: We avoid combined hormonal contraception in migraine with aura due to stroke risk. Continuous/extended regimens may help menstrual migraine in appropriate patients.

When is it best to refer, and to whom: headache specialist or women’s health/menopause specialist?

Most migraines in midlife can be managed in primary care, but referral is helpful when symptoms are severe or not improving. If the pattern is clearly hormonal, the patient has significant vasomotor or genitourinary symptoms, or is considering MHT, an ob-gyn or menopause specialist can help.

A headache specialist is key for more complex or treatment-resistant cases where there may be diagnostic uncertainty, medication overuse and aura changes. For patients with persistent symptoms, a team-centered approach is often the most effective path forward.

Many patients benefit from both, especially if migraines are hormonally sensitive.

What should be included in the referral?

●Headache phenotype (with/without aura), frequency, disability

●Timeline relative to menstrual/hormonal changes

●Prior and current treatments (doses, responses, adverse effects)

●Comorbidities (mood, sleep, vascular risk factors)

●Current hormone use or plans for MHT

●Red flag evaluation already completed

What does an ideal shared-care model look like between ob-gyn and headache specialist?

An ideal model is team-based, with ob-gyns focusing on hormonal stability and gynecologic risks and a headache specialist managing migraine-specific therapies. Our shared goals are to minimize hormonal fluctuations, avoid contraindications (e.g., estrogen in aura with high vascular risk), coordinate medication changes and monitor outcomes with a unified plan. We work very well together and can now use in person consult, e-consults and virtual care consults to meet patients where they are.