Introduction
The years leading up to menopause often bring changes that are easy to dismiss one at a time: lighter sleep, a shorter fuse, and headaches that arrive more often than they used to. Migraine is among the most disruptive of these changes, yet it is rarely the first thing women connect to the hormonal shifts of midlife. Botox, better known for its cosmetic use, has become an established preventive treatment for chronic migraine, although many women only hear about it in passing from a friend.
Ask Dr. Lili exists for questions like this one, where a reader’s experience deserves a careful, evidence-based answer from a physician who sees these concerns in practice. This month, a reader from Coquitlam asks why her migraines have worsened in perimenopause and whether Botox could be the answer.
The Question
Dear Dr. Lili,
I’m 49 and have had occasional migraines for years, usually around my period. Over the past year they have become much more frequent and unpredictable. My periods are irregular now, I’m not sleeping well, and some months it feels as though I have a headache more often than I don’t.
A friend told me she gets Botox for migraines. I thought Botox was for wrinkles! Can Botox actually help migraines during menopause?
Samantha, Coquitlam
Dr. Lili’s Answer
Dear Samantha,
Yes, Botox can be an effective treatment for chronic migraine, and this is something many women are surprised to learn.
But there are really two questions in what you’re asking. First, why have your migraines suddenly become worse? And second, would Botox be an effective and appropriate treatment for menopause migraines like yours?
Perimenopause can change a woman’s migraine pattern. But Botox isn’t a treatment specifically for menopause or hormonal migraines. It is an established preventive treatment for people who meet the criteria for chronic migraine, let’s separate the two.
Why Can Migraines Get Worse During Perimenopause?
Women frequently tell me that symptoms they previously had under reasonable control seem to become unpredictable during their 40s. Migraine can be one of them.
Estrogen doesn’t simply decline in a straight line during perimenopause. It can fluctuate quite dramatically before eventually settling at lower levels after menopause. These hormonal fluctuations can influence the neurological pathways involved in migraine, and women who have previously experienced menstrual migraines may be particularly sensitive to changing estrogen levels.
At the same time, several other common symptoms of perimenopause can make migraine more difficult to manage. Sleep may deteriorate, hot flashes and night sweats may wake you repeatedly, stress may increase, and eating and exercise patterns may change.
In other words, hormones may be part of the story, but they aren’t necessarily the whole story. This is why I always come back to something I tell my menopause patients frequently: we need to look at the whole woman.
What Exactly Is Chronic Migraine?
This distinction is important because Botox is not used simply because someone occasionally experiences a migraine.
Chronic migraine generally means headaches on at least 15 days a month for more than three months, with migraine features on at least eight of those days. In Canada, Botox is approved for the prevention of headaches in adults with chronic migraine. That is very different from having one or two migraines a month.
One of the first things I recommend when headaches are becoming more frequent is keeping a headache diary. Record when the headache occurs, how long it lasts, whether it has migraine features, what medications you take, your menstrual cycle if you are still having periods, and potential triggers. Sometimes women don’t realize just how many headache days they are actually experiencing until they start counting them.
How Does Botox Help Migraine?
Botox (onabotulinumtoxinA), a form of botulinum toxin therapy, is probably best known for temporarily relaxing the muscles responsible for facial expression lines. Its effect in migraine is more complicated.
Botox affects nerve signalling and inhibits the release of substances involved in pain pathways. When Botox injections for headaches are given according to the chronic migraine protocol, they can decrease the frequency of headaches in appropriate patients.
Migraine Botox is not the same treatment as cosmetic Botox. The standard chronic migraine protocol involves multiple small injections across specific areas of the forehead, temples, back of the head, neck and shoulders. It is typically injected in 31 sites across the head, neck and shoulders with treatment repeated about every 12 weeks. Although the medication is the same, the purpose, dose and injection pattern are very different.
How Effective Is Botox for Chronic Migraines?
Botox isn’t a cure for migraine, and I think it is important to set realistic expectations. The goal is fewer headache days, less severe attacks and less disruption to your life rather than a guarantee that headaches will disappear completely.
Response varies from person to person, and it may take more than one treatment cycle before we can adequately judge the benefit. For someone who has spent years organizing work, family activities and social plans around migraines, even a meaningful reduction in migraine days can make an enormous difference.
What About Hormone Therapy?
This is where treating migraine during perimenopause becomes more nuanced. If a woman’s migraines have worsened at the same time as significant hot flashes, night sweats, sleep disturbance and other symptoms of menopause, I don’t want to look at the headache in isolation.
Hormone therapy may be appropriate for some women who have bothersome menopausal symptoms, but menopausal hormone therapy is not prescribed simply as a migraine treatment. Migraine history, including whether a woman experiences aura, and her overall cardiovascular and medical history need to be considered when choosing treatment.
Sometimes headache management strategies, such as improving sleep and treating hot flashes and other migraine triggers, are an important part of the overall plan. And sometimes a woman needs both menopause care and a separate migraine prevention strategy.
Is Botox Right for Everyone With Migraine?
Botox is specifically used for chronic migraine, so someone experiencing occasional migraines may be better served by other migraine prevention methods.
There are many migraine treatments available today beyond Botox. Treatment should be individualized according to migraine frequency and severity, other medical conditions, medications and patient preference.
New or changing headaches also deserve proper assessment rather than automatically being attributed to menopause. A sudden, severe headache; new neurological symptoms; or a significant change in a longstanding headache pattern calls for prompt medical evaluation.
What Are the Botox Side Effects for Migraine Treatment?
Most people tolerate treatment well, but Botox is still a prescription medication and should be administered by a physician trained in the chronic migraine injection protocol.
Possible adverse effects include discomfort or bruising at the injection sites and temporary muscle weakness. Migraine Botox is a medical treatment that begins with an appropriate diagnosis.
Looking at the Whole Woman
If your migraines become worse during perimenopause, you don’t have to assume that you simply have to live with them until menopause is over. Menopause headache relief starts with looking at the headache pattern, your sleep, medications, stress, menstrual changes and other potential triggers. Determine whether you have episodic or chronic migraine. And if you’re also struggling with other symptoms of perimenopause, those deserve attention too.
Then we can choose the treatment that actually fits the problem. For the right patient with chronic migraine, Botox can be an effective part of that plan.
So, Samantha, you do not need to suffer through frequent migraines. We can work together to find a treatment plan that helps you.
Have a Question for Dr. Lili?
Menopause, skin, hair, hormones and healthy aging: there are so many questions women have that don’t always get answered. Ask Dr. Lili is a place for real questions and evidence-based answers.
Have a question you’d like me to answer in a future column? Send your question through our Contact Us form. Questions may be edited for length or clarity, and identifying details will not be published.
If you are experiencing frequent migraines or headaches during perimenopause or menopause, you can also book a consultation at Healthy Skin Centre in New Westminster to discuss your symptoms and appropriate treatment options.
Ask Dr. Lili provides general health information for educational purposes and is not a substitute for individualized medical advice.
About Dr. Lili
Dr. Lili Nasseri is a family physician with more than 20 years of clinical experience, a Menopause Society Certified Practitioner (MSCP), Clinical Instructor at the University of British Columbia, and co-founder of Healthy Skin Centre in New Westminster, BC. She is also the author of the upcoming book The Menopause Method, an evidence-based guide to helping women better understand perimenopause, menopause and the years that follow.