Fluctuating estrogen levels and menstrual disorders are associated with increased migraine prevalence during the perimenopause. However, effective management of vasomotor symptoms can also result in improvement in migraine.

What are the key points about managing perimenopausal women with migraine?

  • Perimenopausal women with no history of migraine aura may benefit from continuous combined hormonal contraception until age 50
  • Migraine aura does not contraindicate HRT
  • Use non-oral bio-identical estrogen (patch or gel)
  • Use the lowest estrogen dose that effectively controls vasomotor symptoms
  • Where progestogen is required continuous delivery is recommended, with preparations such as:
    • levonorgestrel intrauterine system
    • transdermal norethisterone (as in combined patches)
    • micronised progesterone
  • Women with migraine and vasomotor symptoms who do not wish to use HRT or in whom estrogens are contraindicated may benefit from escitalopram or venlafaxine

How do I know if a woman has migraine headaches?

Does she have episodic headache attacks lasting 4-72 hours?

If yes, then ‘PIN’ the diagnosis of migraine headache with ID-Migraine™:

PhotophobiaDoes light bother her when she has a headache?
ImpairmentDoes she experience headaches that impair her ability to function?
NauseaDoes she feel nauseated or sick to your stomach when she has a headache?

If the answer to at least two out of three questions is ‘yes’ a diagnosis of migraine headache is likely.

How do I know if a woman has migraine with aura?

Does she have visual disturbances that:

  • Start before the headache?
  • Last up to one hour?
  • Resolve before the headache?

If the answer to all three questions is ‘yes’ a diagnosis of migraine aura is likely

What non-pharmacological options are there which have evidence of efficacy for management of vasomotor symptoms and prophylaxis of migraine?

  • Regular exercise
  • Weight loss

What pharmacological options are there which have evidence of efficacy for management of vasomotor symptoms and prophylaxis of migraine?

Treatment Dose
Post hysterectomyContinuous transdermal estrogenLowest estrogen dose required to control vasomotor symptoms
Uterus intact: premenopauseContinuous transdermal estrogen plus LNG-IUS
Uterus intact: postmenopauseContinuous transdermal estrogen plus LNG-IUS

Continuous combined estrogen/progestogen patches

Continuous transdermal estrogen plus micronized progesterone


SSRIsEscitalopram10-20 mg/day
SNRIsVenlafaxine37.5-150 mg/day

LNG-IUS, levonorgestrel intrauterine system; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin norepinephrine reuptake inhibitor


For healthcare professionals –

For women –


Lipton RB, Dodick D, Sadovsky R, et al. A self-administered screener for migraine in primary care: the ID Migraine validation study. Neurology 2003; 61: 375–382.

MacGregor EA. Diagnosing migraine. J Fam Plann Reprod Health Care 2016; 42: 280–286.

MacGregor EA. Migraine, menopause and hormone replacement therapy. Post Reproductive Health online       early DOI: 10.1177/2053369117731172.

Author: Professor Anne MacGregor in collaboration with the medical advisory council of the British Menopause Society.

  • Publication date: October 2018
  • Review date: October 2021

Information for women

There is a factsheet aimed at women available on the WHC website