Migraine with aura at the menopause: can you take hormone therapy, and which options are safe?

Having migraine with aura does not on its own stop you from using hormone therapy at the menopause. UK and Australian clinical guidelines consider it compatible as long as oestrogen is given transdermally (patch, gel or spray), at the lowest dose that controls symptoms, and the aura is monitored. If the aura comes back or gets worse on treatment, the treatment is stopped.

There is more to that answer than meets the eye: why the menopause stirs up migraine, where the fear of stroke comes from, how hormone therapy differs from the contraceptive pill, and which non-hormonal options exist. Let's take it step by step.

Why migraine changes as the menopause approaches

Migraine is very common. According to the Spanish Society of Neurology (SEN), more than 5 million people in Spain have migraine, 1.5 million of them in its chronic form, and it is around 3 times more common in women. Much of that difference comes down to oestrogen.

According to a narrative review on migraine and menopause published in PubMed, what matters most is not whether oestrogen levels are high or low, but whether they change. A sudden drop in oestrogen tends to trigger menstrual migraine without aura, whereas high levels can trigger aura. During the perimenopause hormone levels rise and fall irregularly for years, which is why this stage is linked to more migraine, especially menstrual migraine, that is more disabling and responds less well to usual treatment.

It is not true that migraine always goes away after the menopause. Every woman's migraine evolves differently, and there is no way of knowing in advance how yours will change.

The fear of stroke: what the data show

The concern is well founded. A meta-analysis published in the BMJ in 2005 (Etminan and colleagues) found that migraine with aura is associated with a relative risk of ischaemic stroke of 2.16, in other words slightly more than double that of people without migraine. In migraine without aura, the increase observed (1.23) was not statistically significant. In women who had migraine and were also taking oral contraceptives, the relative risk reached 8.72.

That last figure is the one most often quoted, and it is frequently misread. It refers to the contraceptive pill, not to menopausal hormone therapy. Combined contraceptives contain oestrogen at doses designed to block ovulation. Menopausal hormone therapy aims to replace low levels and, when given transdermally, to keep them steady. Their risks are not equivalent, so the fact that the pill is advised against in migraine with aura does not mean hormone therapy is too.

Nor should you go to the opposite extreme: migraine with aura does carry its own cardiovascular risk. That is why blood pressure, smoking and other risk factors are also taken into account when choosing a treatment.

Hormone therapy with migraine with aura: how it is approached

According to the NHS clinical resource BNSSG Remedy, which refers to the British Menopause Society's tool, and according to the Australasian Menopause Society, migraine with aura does not on its own contraindicate menopausal hormone therapy. What changes is how it is used. The guidelines agree on the following points:

• Transdermal route. An oestrogen patch, gel or spray, because these give steadier hormone levels than tablets. Of these, the patch is the preferred option.
• Low dose. Treatment starts at the lowest dose that controls symptoms and, if needed, is increased gradually, to avoid peaks that could trigger aura.
• Protecting the womb. If you still have your uterus, a progestogen must be added continuously: a 52 mg levonorgestrel IUD, a combined patch with norethisterone, or micronised progesterone.
• Monitoring the aura. According to a review in BMJ Sexual & Reproductive Health, if the aura comes back or gets worse during treatment, the treatment should be stopped.

If you would like to understand these elements better, we have more information on what menopausal hormone therapy is, who it is for and its real risks and on estradiol and micronised progesterone in modern hormone therapy.

In some women, steadier oestrogen levels may reduce how often migraine occurs, but there is no reliable figure for how much. Nor have we found a specific position statement from the Spanish societies (the Spanish Menopause Society, AEEM, and the Spanish Society of Neurology, SEN) on migraine with aura and the menopause, so these recommendations come from UK and Australian guidelines. Choosing a treatment remains an individual decision that takes into account the type of aura, your medical history and any other risk factors.

Non-hormonal alternatives for hot flushes

If you do not want to, or cannot, use hormone therapy, fezolinetant (brand name Veoza, 45 mg) is authorised in Spain. It is a non-hormonal treatment for moderate to severe hot flushes and night sweats associated with the menopause, with a summary of product characteristics and patient leaflet approved by the Spanish Agency of Medicines and Medical Devices (AEMPS) and an assessment by the European Medicines Agency (EMA).

There are two important caveats. First, there are no specific data on fezolinetant in women with migraine, so it cannot be said to improve migraine: its role is to control hot flushes. Second, in January 2025 the AEMPS sent healthcare professionals in Spain a safety communication, at the request of the European pharmacovigilance committee (PRAC), about the risk of liver injury. It recommends liver function tests before starting and every month during the first few months. We explain this in detail in our article on fezolinetant (Veoza) for hot flushes without hormones.

What to bring to your appointment

To help your doctor assess your case properly, it is useful to arrive with a record of your attacks over a few weeks: how many migraines you have, whether they come with aura and what it is like (visual, sensory, affecting speech), whether they coincide with your period or with changes in your cycle, and what medication you use for attacks. It is also worth mentioning whether you smoke, what your blood pressure is like, whether you have had a thrombosis and whether anyone in your family has had a stroke. With that information, it is possible to decide whether the transdermal route is suitable, a non-hormonal alternative, or neither.

In summary: what options are available

Having migraine with aura does not leave you without treatment at the menopause. It changes how treatment is approached: low-dose transdermal oestrogen, monitoring of the aura and, if that is not suitable, non-hormonal alternatives with their own monitoring. In Spain, medical treatment for the menopause is available with a prior assessment, a prescription from a registered doctor where appropriate, and ongoing follow-up, which is what AiON offers through telemedicine. If you would like to know what might suit you, you can:

Check in a few minutes whether menopause treatment is right for you