Why Migraines Can Worsen for Women in Their 40s and Why Hormone Therapy May Help Some Women but Not Others

Women in their 40s may experience worsening migraines as oestrogen levels fluctuate during perimenopause, neurologist Dr Jessica Ailani has said. The director of the MedStar Georgetown Headache Center discussed the condition in a CBS News interview.

But hormone replacement therapy (HRT) does not help everyone. UK medical guidance says it can ease migraine attacks for some women while worsening them for others. The type of treatment and an individual's symptoms can make a difference.

Migraine is a neurological condition that can cause severe head pain, nausea and sensitivity to light or sound.

Women are roughly three times more likely than men to experience it, with hormonal changes thought to contribute to that difference.

Why Migraines Can Worsen During Perimenopause

Ailani described the 40s as a period when migraine attacks can intensify. Oestrogen levels often become less predictable during perimenopause, the transition leading up to menopause, potentially triggering more frequent attacks.

Hormones are only part of the picture. Ailani described migraine as 'primarily a genetic disorder', although its precise causes remain incompletely understood. Susceptibility can run in families, and changes in neurological signalling are also involved.

Migraine patterns can change again after menopause. As hormonal fluctuations settle, some women experience fewer attacks, although improvement is neither immediate nor universal.

Ailani observed that 'for many women migraine improves'.

Why Hormone Therapy May Help Some Women but Not Others

HRT is primarily used to relieve menopausal symptoms, such as hot flushes and night sweats. It is not a standard treatment for migraine itself, even though controlling menopausal symptoms can help some women experience fewer attacks.

The Migraine Trust says HRT improves migraine for some people but makes it worse for others. Treatments that produce greater hormonal fluctuations can contribute to attacks, making the form of HRT particularly important.

For women with migraine who need HRT, UK guidance generally favours oestrogen patches, gels or sprays over tablets because they provide steadier hormone levels. Doctors are also advised to use the lowest effective oestrogen dose for menopausal symptoms.

Migraine with aura, which can involve temporary visual disturbances, does not automatically prevent a woman from using HRT. Decisions should consider her symptoms, medical history and individual risks.

Ailani recommends consulting a doctor when migraines emerge around menopause.

Other Migraine Treatments and When To Seek Help

'One treatment doesn't work for every patient,' Ailani said.

Options include CGRP-targeting medicines, some of which help prevent migraine attacks, and Botox injections for eligible patients with chronic migraine.

UK guidance restricts Botox treatment to people who meet specific criteria after other preventive medicines have proved unsuitable or unsuccessful.

Non-drug treatments are available, too. Remote electrical neuromodulation devices worn on the upper arm stimulate nerves involved in regulating pain signals. Their suitability depends on the patient and the device.

Ailani emphasised that migraine can begin before head pain and leave patients fatigued afterwards.

Warning symptoms may include food cravings, neck discomfort and sensitivity to light, while concentration problems can persist after an attack.

For women whose migraines change during midlife, her advice is to seek medical assessment rather than dismiss recurring symptoms. 'Put yourself first,' Ailani said.