Migraine may emerge at the perimenopause, or existing migraines may get worse, due to fluctuating hormone levels. Some women may vaguely recall suffering from them when their periods first started. Migraine with aura, where women see a kaleidoscope effect, may also be experienced as dizziness or vertigo known as vestibular migraine. Coupled with disturbed sleep, they can become frequent and debilitating. Low oestrogen levels have a tendency to cause headaches and this may be noticed during a period, in contrast auras tend to be associated with high levels of oestrogen. For the majority of women experiencing menopause, progestogen is purely given to protect the lining of the womb from thickening in response to oestrogen, however, for women with migraine it can also be necessary to stabilise these levels too. It can be reassuring to know that migraines will pass in the post-menopause when hormones remit, and they can be safely and well managed by hormone replacement therapy (HRT). When compared to the contraceptive pill, HRT contains a much more natural oestrogen and can be administered via the skin in a patch so HRT is not associated with stroke in the same way as the pill for those women with migraine with aura. Perhaps one of the best combinations of HRT for such women is an oestrogen patch alongside a Mirena coil in providing a stable hormonal environment and doses must be titrated slowly. You may find the Headsup podcasts about ‘Hormones and Migraine’ helpful and the National Migraine Centre offers donation-based consultations.