The link between menopause headaches and high blood pressure - what does it really mean?

During perimenopause - the period leading up to the menopause - hormonal fluctuations become more pronounced and irregular, which can intensify both the frequency and severity of migraine headaches. For many women, though, once menopause is behind them, they then report a spontaneous improvement as hormone levels stabilise at lower levels.  

"Highlighting this link between the menopause and headaches is essential so that women who suffer from it don't feel alone," explains gynaecologist Dr Teresa Aznar. "They can then identify the cause and seek professional help, and understand that they're not imagining these symptoms.

"These issues are actually part of a complex network of biological changes. A diagnosis is the first step to effectively tackling these challenges and improving the quality of life for women in menopause."

Neurologist Dr Jorge Uriel Máñez Miró notes that the relationship between hormonal changes and headaches is well-documented - in fact, many women experience migraines linked to their menstrual cycle.

"[This type of headache] is mainly due to fluctuations in oestrogen levels," he says. "When oestrogen levels drop sharply - as also happens during the menopausal transition - headaches are more likely to occur."

Key causes of headaches and migraines during menopause

Headaches during the menopausal and perimenopausal period are a very frequent symptom for women, but what more specifically causes them?

Gynaecologist Dr Inés Blasco explains that the principal trigger for this type of headache is the vasomotor disorder that is a secondary result of the drop in oestrogen levels. (Oestrogen plays a key role in keeping blood vessels flexible and dilated. As these levels decline, that protective effect is lost, leading to an increase in arterial resistance.)

This decline can manifest in various physical ways, not just headaches, but also: sweating/hot flushes, heart palpitations, dizziness, irritability, poor concentration, memory loss and 'brain fog'.

"The increase in arterial resistance can also lead to episodes of high blood pressure (hypertension) - a condition frequently diagnosed during this stage in women and which usually presents with headaches as the main symptom," says the gynaecologist. She adds that most women report this symptom as severe, but only 20-30% seek medical attention for its treatment or evaluation.

"Approximately 70-80% of women report experiencing some of these symptoms, with 25% describing them as moderate or severe. Up to 10% say they genuinely interfere with daily life," says the doctor. "The average duration is around 4.5 years from the last menstrual period, though this can be longer in women who experience an earlier menopause."

How lack of sleep contributes to menopause headaches

Another potential cause of headaches during this stage, Dr Blasco highlights, is sleep - or, actually, the lack of it. "The hormonal changes associated with perimenopause and menopause have been linked to an increased risk of suffering from sleep problems, including both insomnia and poor quality sleep.

"It is estimated that these disturbances can affect anywhere from 35% to 60% of patients in menopause and postmenopause," she states.

The expert adds that this difficulty in both falling asleep and staying asleep worsens throughout the menopausal transition, often resulting in other common symptoms such as daytime headaches, heightened irritability, fatigue and brain fog.

How oestrogen and testosterone fluctuations trigger migraines

Changes in the frequency and intensity of migraines during perimenopause and menopause are directly related to hormonal fluctuations - not just oestrogen, but also testosterone - which affect the central nervous system and the pain threshold.

Oestrogen: The primary hormonal trigger

During perimenopause, oestrogen levels rise and fall erratically, which can trigger or worsen migraines.

Levels stabilise following the menopause, meaning some women see an improvement. Others, though, continue to suffer from migraines, particularly if other factors are present (stress, insomnia or lifestyle changes, for example).

Hormone replacement therapy (HRT) can be beneficial, but it must be individually tailored. If it is administered transdermally, via patches or gels for example, this usually results in fewer fluctuations and better tolerance. High or poorly adjusted doses can, conversely, worsen migraines.

Testosterone: The forgotten female hormone

You might associate testosterone with men, but this hormone also declines with age in women, too.

In fact, low testosterone levels can:

• Lower your pain threshold.
• Increase neuronal sensitivity.
• Be linked to fatigue, insomnia and mood changes, which, in turn, can encourage the onset of migraines.

Some women with persistent migraines during the menopause show improvement by incorporating small doses of bioidentical testosterone into their hormonal treatment regimen.

When to seek help

Dr Aznar considers that hormonal balance during the menopause transition is absolutely key. "It's not just about compensating for the oestrogen deficit, but also about rebalancing the entire hormonal axis, including progesterone and testosterone, and adapting the approach to each patient's unique profile," she explains.

An individual assessment, which includes an examination of symptoms, migraine history and hormonal analysis, allows a healthcare team to design a truly personalised therapeutic approach.

"It is vital that women who experience severe or persistent headaches during the menopause consult a healthcare professional to receive a proper diagnosis and explore suitable treatment options," insists gynaecologist Dr Ernesto Bas.

Effective treatment options for menopausal headaches

Fortunately, there are multiple therapeutic strategies available to address this issue. These range from personalised hormonal treatments to non-hormonal approaches such as physiotherapy, magnesium supplements, relaxation techniques or specific migraine medications.

"Ideally within the first hour of the onset of head pain, you can take conventional anti-inflammatories such as naproxen, ibuprofen or dexketoprofen, alongside triptans, which are specific medications designed for migraines," explains Dr Miró. "Recently, the gepant family of drugs has become available for those cases that aren't responsive to the other treatments mentioned."

Dr Blasco, meanwhile, suggests, "It's important to promote regular exercise and a healthy diet. There are also supplements that have been efficient in improving vasomotor symptoms during the menopause, such as soya phytoestrogens, fresh sage leaves, cytoplasmic pollen extract and hops. To help with insomnia, I recommend the use of supplements like melatonin, passionflower, valerian, lemon balm and California poppy."

It is important not to normalise headaches and simply accept them as inevitable. "Women who experience intense or persistent headaches during the menopause should consult a healthcare professional for an appropriate diagnosis and treatment," advises Dr Miró. 

Also key: ruling out other underlying conditions that may involve headaches as a symptom, such as high blood pressure, hyperthyroidism or neurological problems.

The vicious circle: More on sleep & menopausal migraines

During the menopause, partly due to hot flushes, women may rest less well and have poorer quality sleep. "This lack of quality nighttime rest can increase the frequency and intensity of headaches, especially migraines," comments Dr Aznar.

It creates a vicious circle: Headaches prevent you from sleeping well, and poor sleep predisposes you to more headaches - a loop that is difficult to break unless both problems are addressed simultaneously.

Poor sleep affects headaches because it:

• Lowers the headache pain threshold: Insufficient or fragmented sleep alters pain perception at the level of the central nervous system. This causes neuronal hypersensitisation, which facilitates the appearance of migraines even in the face of mild stimuli.
• Deregulates the Trigeminal-Vascular System: Lack of sleep over-activates this system, which is normally calmed during rest. This over-activity encourages the inflammation that causes migraines. 
• Unbalances key neurotransmitters: Sleep deprivation affects serotonin, dopamine and melatonin, all of which are deeply involved in how our body modulates pain. Poor regulation of melatonin, in particular, is strongly associated with more frequent and more intense migraines.

"This is all intensified during the menopause," says Dr Aznar. "Insomnia is very frequent during this phase, due to the hormonal drop. Night sweats, anxiety, and depression also impair sleep quality. All this aggravates pain sensitivity and facilitates chronic migraines."

About the experts:

• Dr Teresa Aznar is specialised in aesthetic, functional and regenerative gynaecology at Vithas Castellón Hospital.
•  Dr Jorge Uriel Máñez Miró is a Neurologist at Hospital Vithas Turia and Hospital Vithas 9 de Octubre in Valencia, Spain.
• Dr Inés Blasco is a Gynaecologist at Hospital Vithas Medimar in Alicante, Spain.
• Dr Ernesto Bas is a Gynaecologist at Spain's Vithas Valencia Consuelo Hospital.