Headaches are a common health concern, affecting nearly 50% of the population, with migraines being one of the most prevalent types. While women are more likely to suffer from headaches due to hormonal fluctuations, understanding the connection between hormone therapy (HT) and headaches is essential. For women considering hormone therapy for various reasons, such as menopausal symptoms, it’s important to assess the safety and risks when dealing with headache disorders, particularly migraines.
Understanding the Different Types of Headaches
Headaches can be broadly categorized into three primary types: migraines, tension-type headaches (TTH), and cluster headaches. Among these, migraines are known to have the most significant impact on quality of life. Migraines are not just a headache but a neurological disorder characterized by recurring, often severe headaches, frequently accompanied by nausea, light sensitivity, and other symptoms. It is important to differentiate between types of headaches, as they present different risks, especially when hormonal therapy is considered.
Migraine Subtypes
Migraine headaches are classified into several types, with the two main subtypes being:
- Migraine Without Aura: This is the most common type and is characterized by a throbbing, unilateral headache. It typically lasts between 4 and 72 hours, often accompanied by nausea and sensitivity to light and sound.
- Migraine With Aura: This type includes sensory disturbances such as visual or speech issues that occur before the headache begins. It is less common but can be more severe and complicated by neurological symptoms.
- Chronic Migraine, occurs when a person experiences headaches 15 or more days a month over three months, leading to a more persistent and debilitating condition.
Hormonal Fluctuations and Headache Triggers
Hormonal changes are a common trigger for migraine headaches in women. Fluctuations during menstruation, pregnancy, and menopause can be linked to the onset of headache episodes. In women who still menstruate, the hormonal contraption can reduce headache frequency due to the suppression of ovulation and menstruation and is a very effective treatment for “menstrual migraines”. In perimenopause and menopause, erratic fluctuations in hormonal patterns cause a multitude of symptoms, most commonly, hot flashes. Hormone therapy is the first line treatment for hot flashes, however, in women with migraine headaches, there is concern for the risk of stroke given that these women are often older and may have other risk factors increasing the potential for stroke.
The Relationship Between Hormones and Stroke Risk
While migraines are associated with an increased risk of stroke, the link between hormonal therapy and stroke risk remains a subject of ongoing research. Studies have shown that women with migraines, especially those with aura, face a higher risk of stroke compared to those without migraines (4 cases per 100,000 people without aura and 5.9 cases per 100,000 people with aura). The use of hormonal contraceptives has been found to further increase this risk to 25.4 cases per 100,000 without aura and to 36.9 cases per 100,000 with aura.
In contrast, menopausal hormone therapy (MHT) typically involves lower doses of estrogen and can have different effects on stroke risk. Though limited studies have focused on menopausal women with migraines, it is generally believed that the risk trends seen in younger women may continue into menopause.
Risk Factors for Stroke and Migraine History
When assessing the safety of hormone therapy in women with migraine headaches, it is important to consider the concept of absolute risk and relative risk. As noted above, there is a clear increase in the number of stroke cases per 100,000 individuals with hormonal contraceptive therapy in the presence of headaches with and without aura. However, the absolute risk of stroke at 36.9/100,000 is 0.03%. So although there is a dramatic increase in relative risk compared to those women not taking hormonal therapy, the absolute risk of having a stroke is quite low. Therefore, the potential benefits to quality of life and symptom relief may outweigh the risk of stroke even in women with migraine with aura.
For menopausal and perimenopausal women considering menopausal hormone therapy, it is important to consider other risk factors for stroke given older age and other medical conditions often found in this population. These include obesity, high blood pressure, smoking, diabetes, and a family history of cardiovascular diseases. The presence of these additional risk factors can increase the overall risk of stroke when combined with a history of migraine headaches and must be considered in the risk/benefit equation.
Approaches to Hormone Therapy for Women with Migraines
If you’re a menopausal woman suffering from migraines and are considering hormone therapy, there are several key factors to discuss with your healthcare provider:
- Symptom Management: Is hormone therapy the most effective treatment for your symptoms? Consider whether the expected benefits of HT outweigh the potential risks, especially in light of your migraine history.
- Migraine Classification: Determining whether your migraines are with or without aura is important, as those with aura have a higher risk of stroke. A clear diagnosis from a qualified healthcare provider is essential for accurate risk assessment.
- Stroke Risk Factors: Other risk factors, such as obesity or high blood pressure, must be considered when deciding whether hormone therapy is safe. If you have multiple stroke risk factors, your doctor might suggest alternative treatments.
- HT Options: Transdermal hormone therapy, which involves hormone patches or gels, may be safer for some women than oral hormone therapy. The lowest effective dose of estrogen should be considered to minimize risks.
- Progestin-Only Options: For women with high stroke risk, progestin-only hormone therapy or non-hormonal treatments could provide an alternative option.
What About Post-Menopausal Women Who No Longer Experience Migraines?
If you no longer suffer from migraines after menopause, it’s tempting to assume that hormone therapy might be safe. However, even if the frequency of headaches decreases, the underlying neurovascular factors that contributed to the migraines may still pose risks. It’s important to assess your overall health profile and consult with your provider to determine the best course of action.
Choosing hormone therapy for headache management, especially in the presence of migraines, requires careful evaluation and a personalized approach. A healthcare provider, such as Dr. Carla DiGirolamo, can help you assess your risks and benefits to make an informed decision. Be sure to discuss your migraine history, other health conditions, and potential stroke risks before choosing hormone therapy.