Understanding migraines to optimal hormones

Hormonal migraine patterns are usually related to estrogen changes — typically:

• A rise in estrogen is more often linked to migraine with aura
• A drop in estrogen is more often linked to migraine without aura

The timing of the migraine in relation to the menstrual cycle can give powerful diagnostic clues.  

This also helps explain why we see more migraines:

• At puberty and in perimenopause — when hormone fluctuations are more dramatic and unpredictable
• Why migraines can seem to occur every two weeks — because mid-cycle is actually the biggest peak in estrogen, before the calming effect of progesterone kicks in.

Treatment Strategies (and How They Work)

This isn’t an exhaustive list — just some considerations

Progestin Options

• Cerazette (desogestrel) – High rates of anovulation. Can help reduce hormonal flux.
• Double-dose Cerazette – Increases anovulation further and improves endometrial protection (sometimes doubling Cerazette, which has previously worked can be a great option).
• Slinda (drospirenone-only) – Similar goal, arguably better for both ovulation suppression and on menopause guidelines for endometrial protection (also often better tolerated, and less progestogenic side effects)
• Mirena – Can be helpful for some, but because it doesn’t consistently suppress ovulation, migraines may persist.  So I think the use of the Mirena is about setting patients up to succeed.  If migraines continue with the Mirena alone - you are half way there!  Especially if amenorrheic/minimal bleeding you can add in stable doses of hormones.

With progestins overall, you can layer estrogen or HRT on top — and this can actually be done at any age, not just at perimenopause.

HRT + Migraine Support

• Cerazette + HRT – A combination like utrogestan plus estrogen can be helpful (occasionally the mini-pill does the job)
• Utrogestan cyclically – Some people benefit from cyclical dosing, even up to 400 mg in the luteal phase (off-label, but potentially effective).
• Utrogestan continuously – If migraines are triggered by hormone changes, then starting progesterone after ovulation may be too late. Earlier or continuous use may be more effective (sometimes then adding in Cerazette, or the Mirena to enable continual utrogestan use)

COCP Considerations

• Zoely (nomegestrol + body-identical estradiol) – High anovulation rates, and more "natural" estrogen, but technically still a COCP.

For migraine without aura, should this really be MEC 3–4 (ie not recommended/contraindicated)? It's estradiol, like the oral estrogen used in HRT — not ideal, but often acceptable.

In migraine with aura, where hormone withdrawal is a trigger, the benefit-risk conversation can be nuanced:  do we withhold stabilising estrogen even if it might actually reduce stroke risk by preventing the migraine itself?  Just something to be mindful.  As because, if someone has had migraines well controlled on COCP for years (and has heavy periods etc), if they worsen in perimenopause - is it the COCP itself?  Or is it actually the COCP isn't doing the job anymore because of the new big changes...?

Estrogen: Low or High?

• Some migraine sufferers need tiny, steady doses — sometimes only 12.5 mcg at a time (set your patients up to succeed)
• Others need higher doses to buffer fluctuations and provide a consistent baseline (and with migraineurs it may take a real while to build up)
• Patches are often assumed to give stable levels, but real-world data shows wide variation in serum estrogen levels — so always listen to the patient’s experience.
• Adding gel or overlapping patches can help smooth peaks and troughs.
• If migraines appear during estrogen changes, increase very slowly.
• You can even add estrogen at the low points in the cycle or during the natural decline to ease transitions.

If All Else Fails: Go Deeper

• GnRH analogues with add-back therapy – For some patients with debilitating hormonal migraines, this can be life-changing. It's humbling to see how much difference this can make when everything else fails.  But I definitely don't think of this as a 'failure' option.  More to reassure you that there is hope!

Practical Tips

• Print out a menstrual cycle chart and match this to wear the symptoms are.  Also note - are there other perimenopausal/hormonal/PMS symptoms that are new?!?
• Walk through a patient’s migraine history across their life — puberty, pregnancy, contraception, perimenopause.
• If they didn’t get migraines in pregnancy — that’s a clue: hormonal stability helps.
• Most importantly: as perimenopause evolves, so must the HRT regime.

And don’t forget — other perimenopausal changes can exacerbate migraines too:

• Sleep disruption
• Sensory changes
• Stress and anxiety
• Carbohydrate cravings
• Insulin resistance

These may all contribute to an underlying vulnerability that gets expressed through migraine.

I wrote this for my medical colleagues, but I thought sharing it maybe useful..