Managing migraines in perimenopause

March 21, 2024.

Medically reviewed by Patricia Shelton, MD

Recently posted in our perry community:

Hi does anyone get frequent migraines in perimenopause the week after their period. I always get migraines when i have first day of my period but a week later more migraines? I just turned 49. My doctor advised i come off my BCP. Anyone same experience? Oh and my doc looked at me kinda weird when i told her about more migraines after my period??? She has never heard of this ? (You can join the conversation here)


Why do we get migraines?
Can changing hormone levels cause migraines?
What are the common triggers for migraines?
HT and BCP: How can they affect hormone levels?
Medication for migraines

If you’ve ever had a migraine, then you know how much they can interfere with your life. A migraine is a particular type of headache, which can sometimes be very severe. It’s generally accompanied by other symptoms, like nausea and sensitivity to light and sound. Some people also have an unusual visual disturbance known as an aura before or during a migraine. All of this generally makes it very difficult to function.

Migraines are three to four times more common in women than in men. Because hormones play a significant role, many women will find themselves experiencing more migraines during peri. Fortunately, there are some steps you can take to help reduce the number and severity of migraines that you get.

Why do we get migraines?

Even though they affect about 1 in 6 American adults, migraines are still not very well understood. It was previously thought that changes in blood flow in the brain caused migraines, but it’s now believed that although these changes are part of what happens during a migraine, they actually aren’t the cause. 

Instead, the current leading theory is that migraines begin in groups of brain cells that are particularly sensitive. It’s still not certain what causes some people to have these particularly sensitive groups of cells. Low levels of serotonin, which is a neurotransmitter (a chemical used by brain cells to communicate with each other), seem to be involved in the process of triggering their activation.

When the groups of cells get triggered, this starts off waves of activation within the brain. This excessive activity causes a variety of unwanted effects, including inflammation and increased blood flow. All of this leads to pain and other migraine symptoms. Although this is our best understanding right now, scientists are still working to understand this condition better, so we may gain a new understanding with more research.

Can changing hormone levels cause migraines?

Levels of hormones, particularly estrogen, are known to play a role in migraines. Estrogen and serotonin are known to interact – estrogen can alter serotonin levels as well as affect how brain cells react to serotonin. 

This helps to explain why many women tend to experience migraines around the time of their period each month. When estrogen levels drop, migraines are more likely to occur. There’s a sharp drop in estrogen just before your period starts, and this can be a migraine trigger. However, to make things more complicated, high levels of estrogen can also be a migraine trigger for some women.

During peri, estrogen levels are fluctuating. Each time there’s a drop in estrogen levels, this could potentially trigger a migraine. Because of this, some women notice an increase in migraines during peri. In general, if you’ve never had a migraine before, you probably won’t start getting them during peri. However, if you’ve previously experienced migraines – particularly if you tended to get them at particular times in your menstrual cycle – then you might find yourself having more of them during peri.

Although you can’t control the hormone fluctuations of peri, it’s important to remember that there are a lot of other factors involved in determining how often you get migraines, and many of these are things that you can control. For example, making sure to get enough exercise on a regular basis has been repeatedly shown to significantly decrease the number and severity of migraines. If you can determine what your migraine triggers are and avoid them, this will also help to reduce the number of migraines that you experience.

What are the common triggers for migraines?

Everyone’s brain is a little different, and it’s not always obvious what the trigger for a particular migraine was. However, in general, there are some common factors that can trigger migraines, including:

  • Stress. Nearly 80% of people with migraines report that stress and anxiety can be triggers for them. In fact, this is the most common migraine trigger. 

  • Hormone changes. As previously discussed, changes in estrogen levels can trigger migraines. In their reproductive years, many women with migraines tend to get them at certain times during their menstrual cycle. In fact, about 14% of people with migraines report that their migraines are exclusively triggered by their cycle.

  • Lack of sleep. Even one night of poor sleep can trigger a migraine. Anything that interrupts your sleep or causes changes to your usual sleep schedule could be a trigger.

  • Specific foods. Different people respond to foods differently, so the specific migraine trigger foods also differ between people. Some common ones include fatty or fried foods, chocolate, coffee, dairy products, citrus fruits, nuts, tomatoes, and onions. In addition to specific foods, overeating in general can also be a migraine trigger.

  • Lights. Particular types of light can be a migraine trigger. This could be very bright lights, lights that flicker (such as televisions or fluorescent lights), or even being out in the sun without sunglasses. At the same time, people often become much more sensitive to light after a migraine starts, and bright or flickering lights may increase the pain.

  • Alcohol. A significant percentage of people with migraines report drinking alcohol as a trigger. The migraine may occur right away, but it’s more common for the migraine to occur the next day after drinking. Even a moderate amount of alcohol can act as a migraine trigger.

Discovering your personal migraine triggers can sometimes be challenging. Keeping a headache diary, in which you write down when you have a migraine along with tracking factors like your food intake, sleep, and activities, can sometimes help to discover these triggers. Doing this for a few weeks can help you to figure out what’s causing your migraines. Once you know what your triggers are, you can try to avoid them, which should help you to have fewer migraines.

HT and BCP: How can they affect hormone levels?

Because a drop in estrogen can trigger migraines, medications that impact hormone levels can also have an impact on migraines. This includes both hormone therapy (HT) and birth control pills (BCP).

hormone therapy (HT) can help to stabilize estrogen levels during peri. For those who get migraines in response to a drop in estrogen levels, HT may help to reduce the number of migraines that you get. 

However, in women who experience migraines in response to high estrogen levels, HT can sometimes worsen migraines, especially when higher doses are used. In most cases, the doses of estrogen that are used for HT during and after menopause are not high enough to trigger migraines, but it can happen for some women. If you’re using HT and getting more migraines, talk to your doctor about this. They may be able to lower your estrogen dose to help with the migraines, while still addressing your other symptoms.

Hormonal birth control may also have an impact on migraines. Keep in mind that, even in peri, it’s still important to consider birth control – you can potentially get pregnant until after you’ve completely finished menopause. 

Birth control pills (BCP) usually contain both estrogen and progesterone. During a four-week cycle on the BCP, a woman usually takes hormones for three weeks, and then the fourth week of pills are inactive. This is what triggers a period to occur. Other methods of delivering hormones for birth control, such as the patch or the ring, typically work the same way.

When taking the inactive pills, there’s a drop in estrogen levels, similar to what would normally be experienced around the time of menstruation. This drop can trigger migraines in some women. It may help to skip the inactive pills and go straight to another week of hormones – this is sometimes called “continuous” use of birth control pills. 

Although this is considered to be safe, not all women feel comfortable with it. In addition, the dose of estrogen needed for contraception is somewhat higher than what’s needed for HT, and some women may experience migraines because of the high estrogen levels. In this case, continuous use will not be helpful, and may even make things worse.

You could also choose a method of birth control that doesn’t contain estrogen. For example, there are some progesterone-only options, such as the “minipill.” There are also several nonhormonal options, such as an intrauterine device, or IUD. IUDs are extremely effective at preventing pregnancy. Some IUDs deliver low doses of progesterone to the lining of the uterus, and there’s also an option that’s completely hormone-free. In the past, IUDs were only given to women who had previously had children, but this is no longer the case. IUDs are also entirely reversible – after the IUD is removed, your fertility should return to normal. 

For those who are certain that they’re done having kids, another option is surgical sterilization (i.e. “having your tubes tied”). Although this does involve a minor surgical procedure, it offers a permanent way to avoid pregnancy without any hormones.

Medication for migraines

If you experience migraines, there are a few different medications available that may help. There are some medications that address the symptoms of a migraine once you’re already having one (known as abortive treatments), and some that help to prevent a migraine from happening in the first place (known as preventive treatments).

Medications that address the symptoms of a migraine

These medications are known as “abortive” treatments. They may not completely get rid of a migraine once you’re having one. However, they can help to address the symptoms so that you’re less uncomfortable and better able to function. Abortive treatments include:

  • Over-the-counter non-steroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin
  • Prescription NSAIDs, such as ketorolac and piroxicam
  • Triptans, which are prescription medications that act on the serotonin system in the brain
  • Ergotamines, which are an older type of prescription medications that act on serotonin and alter blood flow throughout the body
  • Antiemetic medications, which specifically help to reduce nausea and vomiting

These may help to address the symptoms if you’re experiencing a migraine. Although NSAIDs are available over the counter, they can have dangerous side effects if they’re used too often, so it’s important to avoid doing this. If you have relatively frequent migraines, talk to a doctor about ways to manage them. One of the prescription options may work well for you.

Medications that help to prevent migraines

Preventive treatments may also help to reduce the number of headaches that you have. In general, it’s best to start with trying to discover your triggers and doing your best to avoid them if possible. However, if you do this and you’re still experiencing frequent migraines, then you may want to consider prescription medications to help reduce the number of migraines that you experience. There are a few different options available:

  • Beta-blockers, which alter the activity of multiple different neurotransmitters and are also used to treat high blood pressure
  • Calcium channel blockers, another type of medications that also alter neurotransmitter activity and are also used to treat high blood pressure
  • Antiepileptics, which help to keep brain cells from becoming overactive and are also used to treat seizures
  • Antidepressants, which change the activity of serotonin and other neurotransmitters in the brain

Different options will work well for different people. In addition, all of these medications can cause side effects, which can be worse in some people than in others. You may need to try a few different medications until you find what will work well for you. 

Main takeaways

  • Migraines are fairly common, but researchers still aren’t sure exactly what causes them.
  • Fluctuations in estrogen levels can lead to migraines. Because of this, migraines are more common in peri.
  • HT can help to stabilize estrogen levels and reduce the frequency of migraines in some women.
  • Many factors besides hormones can trigger migraines, including stress, lack of sleep, specific foods, exposure to bright or flickering lights, and alcohol consumption.
  • There are both over-the-counter and prescription medications that can help to treat the symptoms of a migraine and may reduce the frequency of migraines.
  • Every brain is different, so different methods will be effective for each person. It’s essential to take a personalized approach to migraine prevention and treatment.
  • Seek the support of a healthcare professional to help you find the best ways to manage your migraines.
  • Remember that you don’t simply have to live with giving up hours or even days of your life every time you have a migraine. There are effective ways to manage this condition and achieve a better quality of life.


Disclaimer: This is not medical advice.

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