Headaches and migraines

A headache is pain anywhere in the head. Migraine is a particular kind. The NHS describes a migraine attack as a throbbing headache, often on one side, with feeling sick and being very sensitive to light and sound.

Some women get a warning before the pain, called aura: zigzag lines or flashing lights, pins and needles, dizziness or difficulty speaking, the NHS says, lasting no longer than an hour. Whether you get aura matters for treatment, so it is worth knowing.

A head that feels heavy by Asr. A band of pressure round the forehead that never quite clears. A migraine that used to come once a month and now comes when it likes, or stays longer.

Roshara's symptom score puts it as a heavy or tight head, or migraines that changed their pattern. In Urdu most women just say sar dard.

The British Menopause Society's tool for clinicians describes perimenopause as a time of fluctuating estrogen, with menstrual cycle changes and a higher risk of migraine. The NHS headaches page calls it hormone headache and lists it, alongside periods, as a common cause.

The same NHS page lists other common causes: stress, poor posture, eyesight problems, skipped meals, not drinking enough, and taking too many painkillers. A new pattern is a reason to look at all of them.

One hopeful line: the NHS migraine page says migraine in women often gets better after the menopause.

• The NHS suggests a headache diary to find your triggers, and the BMS tool says one can show whether attacks line up with your periods. See trigger tracking.
• The NHS headaches page lists rest, drinking water, not skipping meals, relaxing, and not straining your eyes at a screen for long stretches.
• For migraine in perimenopause, the BMS tool lists a healthy weight, regular exercise, a Mediterranean-style diet, enough fluids and a regular sleep routine, and names aerobic exercise, managing weight and CBT as having evidence for both hot flushes and migraine.

The big question is HRT, and whether migraine changes the answer.

The BMS tool says HRT can be considered for hot flushes in women with migraine in late perimenopause and the early years after the menopause. It prefers estradiol through the skin, as a patch, gel or spray, for steadier levels than tablets, and says migraine aura does not rule HRT out. It adds that the right estrogen dose for a woman with migraine is the lowest one that controls her hot flushes, because high doses can bring more headaches. See estrogen patches and estrogen gel.

The Pakistan Menopause Society's recommendations also prefer the route through the skin for women with migraine, where MHT, their word for HRT, needs adjusting (7.1.1).

The European Menopause and Andropause Society (EMAS) agrees, and explains why aura matters. It says migraine with aura roughly doubles the risk of a stroke caused by a clot, but that aura is not in itself a reason to rule out estrogen. It prefers routes other than tablets, at low doses, because they have little effect on clotting.

So all three point to patches and gels. Whether HRT suits you is your doctor's call, with your history in front of them, and telling them whether your migraines come with aura is one of the most useful things you can bring.

For women who cannot or do not want to take estrogen, the BMS tool names an SSRI and an SNRI that may help both migraine and hot flushes. See SSRIs for menopause.

Book an appointment if headaches keep coming back, if what you do at home is not helping, or if migraines are getting worse, lasting longer than usual, coming more than once a week, or arriving regularly around your period. The NHS lists all of these.

Ask for an urgent appointment, the NHS says, if a headache comes with vision problems, being sick, jaw pain when eating or a tender scalp, or gets worse when you cough, sneeze or bend. The same goes for a migraine lasting over three days, or aura lasting over an hour.

Get emergency help for a sudden, extremely painful headache, or one that comes with numbness or weakness in the face or body, trouble speaking, loss of vision, confusion, a fit, or a high temperature with a stiff neck. The PMS recommendations list a severe new headache as a red flag too.

A fasting day puts two of the NHS's headache causes in one place: no meals and no water until Maghrib. Women ask how to fast with a headache that builds every afternoon. Questions about the fast belong with a qualified scholar. Questions about when to take a medicine in Ramadan belong with whoever prescribes it.

At home, a headache is easy to wave away as tiredness. Written down, with the date and where you were in your cycle, it becomes something a doctor can work with.