The Dr Louise Newson Podcast - 008 - Migraines & Menopause - GP & Menopause Expert Dr Sarah Ball & Dr Louise Newson

Episode Date: July 30, 2019

Migraines and worsening headaches can be a very common symptom of the perimenopause and menopause. In this podcast, Dr Louise Newson speaks with Dr Sarah Ball who explains why this can occur and ways of managing migraines for women who have changing hormone levels. Many women wrongly believe they cannot take HRT if they have a history of migraine, so this myth is discussed and the correct advice given. In addition to taking HRT, there are numerous lifestyle measures that can improve migraines which are also discussed. Dr Sarah Ball's Three Take Home Tips About Menopause and Migraines: Look back at your reproductive cycle as a whole, particularly when your periods first began and when on different contraceptives. Are there any patterns? Keep a headache diary - this can be so helpful! Always look at your lifestyle first as there are lots of helpful changes that can be made. However, don't forget to consider your hormones as this could well be the source of the problem. Learn more about Dr Sarah Ball

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I'm really pleased to have Dr Sarah Ball here with me in the clinic, who, as some of you might know, is one of the doctors who works with me here. She's a GP and has a GP. special interest in the menopause. So we thought today we would cover talking about migraines, headaches, how they can affect women during the perimenopause and menopause and what we can do

about them. So hi, Sarah. Hi, Louise. So just tell me a bit about you and about why you're working here just to introduce yourself to people. So I'm a GP and I've been working in general practice for nearly 20 years and I've always enjoyed working with women related to their hormones which lends itself very nicely to the menopause. And the more and more you absorb yourself in knowing about the menopause, the more you realise that actually the menopause affects us in all sorts of different ways. So it really incorporates the whole of medicine. So let's just go through.

I'm sure most people who will be listening will know. But just what is the menopause? So the menopause is the end of your periods, which is easy to tell if you've gone a whole year without a period. You know that you've reached the menopause, but obviously it can be a bit difficult to tell until you've actually reached that point. But most women won't just suddenly reach the menopause. They will usually go through a period of time called the perimenopause,

where their ovaries are not working so efficiently as before, and therefore their periods have started to alter slightly. And at that point, the women may start to get some. symptoms related to that, which can make her life a little trickier. And it's hard, isn't it? Because so many women during the perimenopause don't realise that the symptoms are related to their changing hormones, which indeed happened to me and lots of people that we talk to. Yes, I think that's the one of the challenges, but also one of the joys about our job in general practice, is that a lot of women don't realize what their symptoms

are related to. And so it's quite easy to go chasing down the wrong path sometimes. So actually to always consider whether hormones could be causing it often brings you to the right path quicker. Yeah. And then what's about people who have had hysterectomy, so had their womb removed, or there's a lot of women now who have or use a marina coil which stops their periods. How do they know when they're going through the menopause? That can be a bit trickier because they haven't got their periods to go on but symptoms should always raise the possibility of a hormonal change and that might be more physical symptoms so things like hot sweats or flushes or joint aches and pains or sleep becoming less good but it might well be psychological problems and women often do struggle to

see the immediate connection between their mood and their hormones but often women in the perimenopause will start to experience low mood, anxiety, sort of irritability. And that can often be a sign. So they need to really think about their hormones with most symptoms, really, don't they? Yes. Something's changed. So we're going to talk today about migraines and headaches. A lot of women are quite surprised when they come in to see me with migraines,

and I'm talking about their periods and how they've changed. Because it's quite hard, isn't it? when you know about your hormones being responsible for your periods and your reproductive track, but how do they get into your brain? Just talk this through the association. Yes, it's tricky, isn't it? Because there's an awful lot of reasons why we get headaches. But we know that women experience headaches far more than men ever do.

So it's about a three to one ratio between headaches that women suffer compared to men. which is strongly suggestive of the fact that hormones plays quite a role in many headaches. And a lot of women, if they were to actually think about it and keep a mental note or a diary, may notice at any point from the beginning of their periods as teenagers all the way through their reproductive lives, that actually their headaches may come in a recognisable pattern in relation to their period cycle. We know that a commonest time for headaches to start in many women is when they have a drop in their natural levels of estrogen, which usually is in the few days leading up to a period. And similarly, if women have been on the combined contraceptive pill, which many younger women are,

when they have that week off and their estrogen levels drop, many women will also experience a headache during that time. drawl time, isn't it? When they... Because a lot of women blame the hormones, but actually it's usually the lack of hormones as opposed to... Yes. So for most women, it's not an overall level of hormones which causes a headache. It's the change, which causes the problem. So either change, after changed down. Yes. So it can be either. And that's why keeping a diary for, say, three months initially will usually start to... pinpoint where the problem lies. So keeping a diary of your headaches alongside a diary of your periods can be really useful. Extremely helpful, yeah. So a lot of women who have headaches around the times

of their periods, like you say, or in that pill-free week, and they more likely to have headaches and migraines during the perimenopause? Yes. So if you've already proven through your reproductive life that you have a sensitivity to hormones, then as you get to the perimenopause, when your hormones fluctuate even more than before. It's going to likely show an even worse effect on headaches and probably most women will experience more headaches of the migraine variety as they get to the perimenopause. So, and then migraine can be triggered obviously by changing hormones, but there's other triggers for migraine as well, aren't they, which there are all sorts. So stress itself will often trigger headaches and migraines. And of course, the

often the psychological and physical symptoms that we experience in the perimenopause can be a source of great stress. Poor sleep will often trigger headaches and it's very common to not sleep well during the perimenopause. And is that because the way hormones affect our brains, isn't it, that women often have poor sleep? Yes. So we have a lot of estrogen receptors in our brain and when our estrogen is fluctuating from very high to very low on an erratic basis, our brain's suffer as a result. If you're getting intense hot sweats or flushes, sometimes that will also trigger a migraine. And we tend to change things like our diet or our alcohol consumption around the time of the perimenopause. And all of those things can also trigger headaches. So all of

these different factors start to gang up on us. And headaches tend to become very bad, almost like a crescendo in the 40s. So it's the worst decade for migraines is in the 40s in women. It's really interesting, isn't it? Because I'm sure, like you, I've seen a lot of women who find that their symptoms are so bad that they are comfort eating and tend to eat more sugary foods. And often with low estrogen levels, there's a bit of a sugar crave isn't there that people have. So, but having fluctuating sugar levels can trigger migraines and headaches as well, aren't they? And then drinking more alcohol, like you say, to sometimes numb the symptoms. Yes.

Can not be great. What about caffeine? Does that kind of affect? Yeah, so caffeine, we seem to become more and more sensitive to caffeine as we get older. And caffeine can have lots of adverse effects on our bodies. For example, we all know that the bladder tends to be adversely affected by caffeine, but also caffeine will tend to adversely affect migraines as well. And we tend to get more tired during the perimenopause. So we'll often drink more caffeine to try and keep us awake, which then gives us some migraine. So we're in trouble again. There's no hope for us, really.

So what can we do? Once we've realised, a lot of us have realised that our migraines or headaches are related to our changing hormone levels, I mean, there's a myriad of it. If you Google migraine treatments, there's so many different treatments. And some of them can be just simple lifestyle changes, can't they, which can be good. and can help with future health. But there's drugs, there's medication, there's, you know, how would you suggest to someone who came to you as migraine?

I think it is taking that sort of multifaceted approach and not just concentrating on one area. So have you said, looking at things like lifestyle and whether we can do relatively simple things, like taking caffeine out of our daily intake. The one thing I would say about reducing caffeine is not to do it all of a sudden because actually if you are having say eight cups of coffee a day and you suddenly go cold turkey you will get a withdrawal headache.

And then you wonder why you're doing this. Yes. So it's best to reduce gradually. And although coffee is the big enemy here, don't forget, tea's got quite a lot of caffeine in it and decaf tea is a good thing to switch to. And also chocolate's got a lot of caffeine in it as well as the obvious Coca-Cola. Yeah. So to try and reduce all them, to look at the intake of our sugar and to try and reduce down the poor carbohydrates that we've had and the sugar levels.

So do you mean things like there's sort of refined sugar, processed foods? Yes. So having a bowl of porridge in the morning, for example, is that a lot better than having a piece of toast? Yes. Yeah. And being careful with avoiding too many sort of white potatoes and pasta and rice because, again, that actually turns itself into sugar quite nicely in our bodies. So should be looking more at whole male foods, whole grains.

It's quite often about the glycemic index, isn't it? Yes. Yes. So this is a helpful thing to look at. Trying to reduce alcohol down, we should recommended limits for women in this country are no more than 14 units per week, which gives us kind of two units per day to place. with, which is a large glass of wine, but actually we should really also be aiming to have three or four days of alcohol free per week. So really just trying to restrict alcohol to small amounts at the weekends would be much better for lots of things, but including headaches.

And it's also drinking, you said about stopping, if you can stop busy drinks or caffeinated drinks, but it's really important that it's replaced with water, isn't it? Yes, yeah, we should be. Yes, enough. Yeah, we should be trying to have at least two litres of water each day. Because actually if you get dehydrated, you're going to get a headache. Yes. So that's important.

Looking at things like painkiller use, it can be a tricky one because simple painkillers, like paracetamolar ibuprofen, can be very helpful at the start of a headache or migraine to kind of stop it in its tracks. But equally, if you overuse simple painkillers like that, you can then end up with a sort of a withdrawal effect as well. And especially if you've ended up having to move on to codeine as a painkiller, that's a very well-known cause of what we call withdrawal headaches, where the headaches are actually caused by the lack of the painkillers. So you can get into a horrible vicious. Because you can buy codeine, can't you, codemortening it over the cancer?

So people think they're doing themselves a favour by medicating. But actually, so if a woman or a person is taking pain killers frequently, they should be looking, do you think, at other treatments? Yes, definitely. Especially, yes, for women, you've really always got to consider whether there's a hormonal element to this. And trying then to discuss with your doctor is really helpful if you do take along, maybe a three-month diary with you that can help to pinpoint any problems. and then to start to think about whether it would be worthwhile trying to stabilise your level of hormones so that you don't get the triggering of the migraines. So it's worth maybe trying some of these lifestyle factors, regardless of hormones, isn't it?

Because obviously it's not just about migraines, but that can really have a positive effect. So with hormones, it can be quite confusing, can't it? So I, for example, have migraines with aura so I can't take the contraceptive pill. So a lot of women then think, well, I can't take HRT. And indeed, we see a lot of women, don't we, who are told incorrectly that they can't have HRT? So do you want to just explain the difference maybe first between the contraceptive pill and HRT? Yes. Yeah, it's a very common area of confusion, both for women, but also for doctors. And it's kind of understandable because actually there is quite a broad similarity between a combined contraceptive pill and HIV.

in that both of them have two hormones, estrogen and progestogen. The difference is that the combined oral contraceptive pill is high dose. It has to be high dose because it's actually temporarily turning off your ovaries. And it's also what we call synthetic. So it's made manufactured hormones. And although that does its job very well, it is a higher dose and it does effectively make our blood a bit sticky and therefore you should not take the combined oral contraceptive pill if you suffer with migraines with aura because there is a doubling of the risk of a stroke. However, HRT, although for all women that have their womb also contains estrogen and progesterone, it doesn't necessarily have to be synthetic hormones and actually a lot of the HRT that we use now is

more naturally occurring, so it's plant-based hormones, and the doses are much lower because actually we're not trying to switch off the ovaries, we're just trying to replace what the ovaries have stopped making. So it is actually a different creature that we're dealing with when we're looking at HRT. So there is no problem with taking HRT if you have migraines, and if you have migraines with aura, so just to clarify, of all migraines, about 30% are migraines with aura. There is no need for you to avoid HRT, whether you have aura or not. The chances are by taking HRT and stabilising your hormones, you will actually reduce the risk of you having migraines going forward. And then having the estrogen, as you say, is this body, usually body identical, derived from the yam, the root

vegetable, but it's best to have it through the skin, isn't it, as a patch or gel? Yes. So, yeah, by absorbing the estrogen, it means in comparison to taking estrogen as a tablet. With the tablet, you actually lose quite a lot of estrogen in the digestion process and the absorption of it from your stomach is actually quite variable. So your levels of estrogen in your blood are not quite as stable if you take it as a tablet. And also when you take estrogen as a tablet, it has to visit your liver in order to be metabolised and that can be a slightly turbulent time and we do have some clotting areas in our liver which can sometimes be accidentally triggered by oral estrogen or tablet estrogen and therefore by taking estrogen through our skin there is no liver metabolism

is it go straight forward into the restraints so you get a much steadier absorption and it's completely safe so it cannot cause a blood clot or a stroke which really makes it the estrogen of choice. That's what we prescribe most of the time. I'm sure you've got a few. I've got a few patients who prefer to take tablets or they're very low risk. But most of the time we prescribe it,

not just for migraine, women who have migraine, but for other reasons as well because it's so well absorbed, it's so easy, isn't it? And although the risk of clot with a tablet, either the contraceptor pill or the HRT tablet is small, if there's an alternative, might as well have the alternative. Yes.

Why take a risk if you don't need to? Precisely. So that's really good. So women who have migraines can definitely use HRT in a different way to those that can't who've had the contraceptive in the past. So gel or patch, what's the difference between the two? So this is just estrogen on its own, gel or patch, isn't it, that you're talking about? So what's the difference?

Both are lovely options. And I do think it's really helpful for women to have an idea of both. so that they can make a choice which suits them on a personal basis. So patches are, there's various different brands of patch available in this country. And most brands of patch available in this country are to be changed twice weekly. So you choose two days of the week. For example, I change mine on a Monday and a Friday. And you will always change your patch on those days.

So it's fairly easy to remember, but you can easily set your mobile phone or a calendar to remind you. And the patches are small and transparent and they stick very well to the vast majority of women's skin. You apply them to clean, dry skin, usually below the waist, so often the sort of top of the buttock area or the top of the thigh. And they should not come off in the shower

or when you're exercising or in a swimming pool. some women will find that the glue in the patch can make them a little bit irritated and red and that's usually helped by moving the patch to a different site each time you reapply and if you do have trouble often a different brand will be more powerful i sometimes speak to women or read on various forums that women are buying plasters to put on top of their patch because they're not sticking. If you get to that stage you probably shouldn't be using that patch should you? If it's not sticking well

or the ends are curling or it's crinkling, you're not absorbing it properly, are you? So it's either trying a different manufacturers like you say, because they all use slightly different glue, don't they? Yes. Or thinking about the gel. Yeah, not the gel. So the gel is, there's

canisters of gel and there's also sachets of gel and it's a daily application. Um, It's a transparent gel which dries after five or ten minutes of being on our skin. And you apply it on clean, dry skin, usually after you've had your bath or shower. It doesn't smell, doesn't it? No, you can't tell it's there after five minutes.

And you rub it in, don't you? Yeah. Because quite a few people feedback to me say, oh, you just leave it to dry on your skin. But it's easier to rub it in, isn't it? I say you don't rub it in as much as you would, like a moisturiser, but you sort of, spread it around and rub it a little, a bit like almost like you're icing a cake, is how I feel it is. And then, yes, and then you just leave it for five minutes, and you avoid cuddling anybody, especially males, while it's drying, so that they don't

absorb it. Or your pets. Yes, all your pets, yes. And then wash your hands after and that's it, isn't it? Yeah. So is there any advantage, disadvantage, do you think, when people have migraines or headaches having the patches or the gels? They're both wonderful options in that they have a big range of doses available. The crucial thing is that you start at a low dose and you work up very gradually. So the way I explain it to my patients is that we are effectively getting on the bottom rung of a ladder and we're going to stay on that bottom rung for usually six to eight weeks so that our body gets used to the estrogen and the levels in our body don't suddenly go up

and then they can reassess how their symptoms are of their perimenopause and whether they feel that they could do with a bit more estrogen and then they can go up to the next rung if they feel they need to so it's a very gradual. Yeah, so more gradual than somebody who you were saying who didn't have migraines for example because often we give quite high duct patches,

quite quickly, don't we? Yes. And certainly I often recommend patches so that it's quite stable, but I usually get them to cut their patches. Is that what you do? Yes. Rather than having two or three different prescriptions, you can have a larger dose and then cut it, and it's not licensed in that way, but because of the way that they're made, it's quite safe to do that. Yes. So it's fine to cut up a patch as long as it's an estrogen-only patch.

You shouldn't cut up a patch if it's a combined patch, because that can then be dangerous because of the progesterone in it. But if it's a pure estrogen patch or whatever make, then you can get away with cutting. And sometimes people just cut the corners off or cut them in cortisol. There's all sorts of ways. But it's doing it gradually because like you were saying, it's this big spike, isn't it, when people have a sudden increase or a sudden decrease.

So doing it gradually is really important. And then they need those women who still got their wombs need to have a progestogen as well, don't they? They do. So what do you normally do? So the progesterogen that's involved in HRT can also occasionally trigger a headache or a migraine because it too is a hormone and it too can fluctuate in amounts. So you've kind of got to be, have your sort of radar on and just be a little bit mindful that we've got two hormones in play and trying to keep an eye on both of them. So the ideal goal with your progestogen is to have as most natural progestergen as possible, to have the dose ideally on a daily basis, which is possible in some people, but it isn't

possible in others. And again, I often ask women when they're starting HRT to carry on their diary for another three months or so, so that if we do run into any problems, we can hopefully pick apart the details and try and work out which hormone is it that we need to think about. So the kind of the nicest options for women with migraines are either a micronized progesterone, which is the naturally occurring progesterone, which also comes from yams. And if a woman has finished her periods, then she can take that every day, and therefore she shouldn't get big fluctuations in levels. If the woman hasn't yet finished her periods,

then she can still use the same capsule of the micronized progesterone, but she does need to take it in a two-week on, two week off, regime. So then the diary is particularly important to see whether the fluctuations are causing any problems. And I have actually seen it go both ways. So I've seen some women who actually find they get a few headaches on the two weeks when they're taking the progesterone. And I've also seen some women where it's the opposite and they get the headaches when they're not taking the projector. And it's so hard to predict, isn't it? The good thing, as you know, about the micronized progesterone is that if it's taken at night, isn't it? It can sometimes

have a slight sedative effect so it can help people sleep. And as you know, when we sleep better, then often migraines can improve. Yeah, there certainly are some women who find that the micro-initis progesterone triggers migraines as well. So sometimes I'll even say have one month just with estrogen on its own and then add in the progesterone carefully. So this is the whole thing, isn't it, that menopause care should be individualised. Yes. And it's it's really important that women have the time, the information, the confidence, because we often, don't we, ask women to try different doses and to be in control of what they're taking once they understand what they're doing? Because that's really important, isn't it?

And I think the other thing is remembering with anything to do with hormones, we should always try and not leap to any quick judgment and try and give any change that we make about three months, because actually a lot of symptoms that we get initially with HRT is purely the change in the status quo in our body and actually if you just see it out you'll tend to find that usually after, it's usually weeks but it can take a couple of months. Most things will settle down if we just be patient. The other thing I just wanted to go back to was that if you are in the perimenopause,

a marina coil can be a really good option for women with migraines because it's a steady low dose of... And that's just the coil with an older progesterine in, but it's very low dose, isn't it? Yes. So it's a brilliant option for many women because it's got sort of three uses. It provides the progestogen component of HRT,

which saves you having to take another tablet. It also will tend to reduce periods, and for many women it will stop them having periods, which can be a godsend. And also you've got a contraceptive in place for five years. So it's got an awful lot of benefits to it. The only thing that I tend to warn women about is that when the coil is first put in, for the first 100 days after insertion, the level of hormone in it is higher than for the rest of the five years.

So you may feel some hormonal effects or a triggering of headaches, for example, in the first few months. I urge patients and it usually settles down. And then the levels drop off nicely and then you just get all the benefits. So that's definitely an option, isn't it? And then just finally, what about supplements? I've read quite a lot about magnesium can help with migraines. Or headaches. Is that something you talk about?

I've certainly heard that and I certainly think that magnesium is gaining, you know, a big fan club for things like sleep but also headache control. Yeah. That's probably one of the main supplements. which... Yeah, I mean, gosh, aren't there? There's so many supplements and it's so much better if women can get what they need from their diet and lifestyle and everything else. But my understanding is magnesium is needed for a lot of cell processes in the body and it's, we can't measure the levels, can we?

Because it's what happens in the cells. And often I'll say to people try good quality magnesium supplement maybe for a couple of months and see how you feel. And it's very hard. I mean, as I've said, migraine and I do all these things that we've been talking about, and I take a magnesium supplement and my migraines, touch would have been good recently. Is it because of one thing or the other? Who knows, but I'm too scared to stop any of them? But it's being sensible, isn't it?

Yes. And it is being patient as well. So Jess, that's brilliant. Thank you ever so much. What I'd like you to do is, Jess, if you can, three take home messages from the podcast today that women could use to reflect and think about migraines and their problems. perimenopause or menopause. Okay.

I think the important thing is always to look back at your whole reproductive lifespan. So think back to when your periods first started and all the years between and see if there's a pattern that you can think of to do with your own natural period cycles or your use of contraception in the past and whether that would help. I think headache diaries can be immensely important. And I think I would say, always look at the lifestyle first because there is an awful lot of important changes that you could make, but you should never then not consider the hormones because that could well be the source of the problem. Totally. Oh, thank you ever so much.

That's been really, really useful. And I think we've covered quite a lot of information in a fairly short period of time. so I hope that's been useful for people to listen to and have hopefully some new knowledge that you can take forward to help yourself and hopefully others as well. For more information about the menopause, please visit our website www.w.menopausedoctor.com.