[00:00]
What if the migraines that suddenly feel more frequent, more intense, and less predictable
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are not random at all, but your brain responding to one of the most hormonally turbulent transitions
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Quick thing before we dive in.
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If you've ever had a blood test or an MRI come back quote-unquote normal and thought
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to yourself, why does my body feel like it's changed?
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Well, that's exactly the kind of thing I'm opening up live Thursday, September 24th.
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Magrainheroes.com slash live.
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Bring your own question.
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I'm answering them in real time.
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Okay, now let's go into the topic of the day.
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Welcome to Magrain Heroes, a podcast for people living with chronic migraines with years of
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pain, misunderstanding, and lack of answers.
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I'm Diane Ducarme.
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I've helped more than a thousand people reduce the burden of migraines and feel more in control.
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My mission in life, to help a million people.
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Each episode brings you grounded insight into what your body might be asking for and what
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Just to keep you fully supported, this podcast is educational.
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For diagnosis or medication, always work with your doctor.
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Now take a breath and let's dive in.
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In this episode, you will learn why hormonal instability matters more than simply having
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low hormones and why the ups and downs of estrogen may make your migraine brain much
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Why symptoms such as poor sleep, hot flashes, anxiety, irregular periods, and migraine can
[01:40]
become tangled together, creating what can feel a vicious cycle.
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A simple strategy you can start at home today to identify your personal rhythm and make
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this phase of life a little less unpredictable.
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Stay with me till the end because at the end of this episode, you will have a simple way
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to start separating what you cannot control, your hormonal transition, from several things
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you may actually be able to influence.
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So if you're in your 40s or early 50s and thinking, what is happening to me?
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My migraines used to make sense or that word was estranged to me before and now they are
[02:15]
taking over my life and I want to acknowledge how unsettling that can feel.
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So perhaps you had migraines once or twice a month and suddenly they're appearing every
[02:25]
week or even worse, every single day.
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Perhaps your medication and other coping mechanisms do not seem to work anymore in the same way.
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Perhaps your period comes after 24 days one month, 38 days the next, and then disappear
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You may sort of sleep badly, you may wake up hot, 3am sharp in the morning, eyes wide
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open, you may feel more irritable or more emotionally sensitive, really on edge.
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And on top of all of that comes a migraine.
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It can feel as though your body has changed the rules without telling you.
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Your body and brain were completely betraying you.
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And this all comes at a time when your children are leaving the nest but still fundamentally
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At a time when your partner is also going through their age changes.
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At a time when your parents need you the most or when you have the highest responsibilities
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At a time when you're contributing to your community and it can feel completely disheartening.
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It's like you've lost your superpowers and you're kind of losing yourself.
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I remember this woman, when we met, she said to me, you know, it's not that I'm suicidal
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I have a husband, I have children, grandchildren.
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In many ways, these are golden years.
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But when I go to bed, I really think to myself, if I don't wake up tomorrow, really, it doesn't
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It's just so hard.
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And so there is a biological reason why the spirit can be particularly difficult for someone
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So I want to talk today about perimenopause and first going to very briefly define it.
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So perimenopause is the natural biological transition leading up to menopause.
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When the body gradually produces less oestrogen and menstrual cycles begin to change.
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So it's often identified by a persistent difference of seven days or more in cycle
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length and may be accompanied by symptoms such as hot flashes, sleep disruption or mood
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Perimenopause is defined primarily by changes in the menstrual cycles rather than a single
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blood test and continues until one year after the final menstruation period, in which case
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we enter menopause.
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During this transition, oestrogen does not simply move gently downward in a straight
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It can rise, it can fall, it can surge and fall again.
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And that distinction matters enormously for migraine.
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Because for migraine brains, the problem appears to be less about one specific oestrogen level
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and more about rapid hormonal changes.
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So in the journal called Maturitas, researchers describe perimenopause as a period associated
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with increased migraine, so particularly menstrual migraine, and highlighted unpredictable
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oestrogen fluctuations as an important contributor.
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So this was in 2020.
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So more recent reviews have reached sort of similar conclusion.
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In 2026, there was a review in Headache and it was saying that unstable oestrogen and
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progesterone during perimenopause were described as factors that can worsen both the frequency
[05:25]
and predictability of migraine attacks.
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So when someone tells you your hormones are normal, they may not tell you the entire story.
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A blood test, for example, is a single photograph, while perimenopause is a changing landscape
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and migraine may be reacting to the shifts happening between vectors.
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So there's a huge oestrogen withdrawal hypothesis in all of that.
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So one of the famous explanations for hormonally associated migraine during perimenopause is
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called the oestrogen withdrawal hypothesis.
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So one of the famous explanations for hormonally associated migraine is called the oestrogen
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withdrawal hypothesis.
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And so the idea is that sufficiently rapid decline in oestrogen can lower the threshold
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at which the nervous system generates a migraine attack.
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This is one reason migraine attacks often cluster around menstruation.
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But there's an important scientific nuance here.
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Although oestrogen withdrawal is widely accepted as a plausible trigger, it has not been conclusively
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proven to explain every menstrual or perimenopausal migraine.
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And I would completely agree with that.
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The nuance is important.
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We do not need to replace one oversimplification with another.
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It's not like oestrogen goes down, therefore migraine happens.
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So your brain is not separate from your hormones.
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So oestrogen receptors are found in areas involved in pain processing and reproductive
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hormones interact with the trigeminovascular system, the network of nerves and blood vessels
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deeply involved in migraine biology.
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Researchers have also become increasingly interested in the relationship between oestrogen
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and other signaling molecules involved in migraine.
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So think of your migraine threshold almost like a glass.
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So your genetic predisposition is going to make the glass in the first place.
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Then hormonal fluctuations will add some water, and then poor sleep will add, and stress will
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Skipping lunch adds some, dehydration adds some, hot flashes add some, and then one day
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the glass spills over.
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And so the migraine may appear to have been triggered by one thing, but biologically it
[07:30]
may have been the sum of several pressures arriving at the same time.
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And so this brings us to something extremely important about perimenopause, is that the
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hormone change is only part of the story, because perimenopause can affect so much more
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than menstruation.
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Sleep fragments, night sweats can wake you repeatedly, mood and anxiety symptoms may
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change, your body temperature regulation changes, menstrual bleeding may become heavier, energy
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can fluctuate, and each of these can potentially interact with migraine vulnerability.
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That is why treating perimenopausal migraine as simply a headache problem can completely
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miss the big picture.
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So there was a 2026 review by Friedman, Korn and Bernstein that emphasized this interaction,
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noting that sleep disturbance, vasomotor symptoms, mood disorders, and metabolic changes
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can complicate migraine management during midlife.
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So imagine someone who already has a sensitive migraine nervous system.
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She begins sleeping five fragmented hours instead of seven, she wakes sweating several
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times each night, her menstrual cycle becomes unpredictable, she's exhausted, so she skips
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breakfast, she increases caffeine just to function, her stress tolerance falls, and
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then she experiences more migraine attacks.
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So was it estrogen?
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Yes, perhaps, partly.
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Was it all those systems interacting?
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Well, very possibly.
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That's why I prefer to think of perimenopause creating a period of reduced neurological margin
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Your nervous system may simply have less room to absorb disruption.
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So how big is this effect?
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Are you alone in this?
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So the increase is large enough to be measurable at a population level.
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There's a study of 3,664 women with migraine, which was published in Headache in 2016, and
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8% of premenopausal women experienced high frequency headaches, so defined as 10 or more
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headaches days per month.
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And during perimenopause, that rose to 12.2%.
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To put it in another way, the proportion of women experiencing frequent headache was
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about 50% higher during perimenopause.
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It's a massive increase.
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So even after researchers accounted for factors such as age, depression, body mass index,
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preventative medication use, and medication overuse, women in perimenopause still had
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42% higher odds of high frequency headache than premenopausal women.
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So this is not simply anecdotal.
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Perimenopause is a recognized period of increased migraine vulnerability.
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It does not mean that every woman's migraine will worsen, but for a meaningful subgroup,
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the transition can push migraine from an occasional problem toward a much more frequent one.
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So I want to talk about why menstrual migraine can become especially difficult.
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So if you already experienced migraine around your period before perimenopause, this transition
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it may become particularly challenging.
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During a predictable reproductive cycle, you might at least have known my period is coming
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Tuesday, and my migraine usually starts on Monday or even maybe on Sunday.
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But perimenopause can move that predictability.
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Ovulation becomes less consistent, cycle length changes, and hormonal peaks and declines become
[10:50]
And so migraine attacks can appear to move around the calendar.
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A 2026 narrative review of perimenopausal migraine described early perimenopause as
[11:00]
a phase in which high and fluctuating estrogen, shorter cycles, and more frequent anovulatory
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cycles may contribute to increased migraine severity and more perimenstrual attacks.
[11:12]
So if your old migraine calendar suddenly seems useless, there may be a reason.
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The rhythm itself is changing.
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Now what about menopause?
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Does it ever get better?
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And so there's some encouraging news.
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So for many women, particularly those with migraine without aura, migraine tends to improve
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after natural menopause, once the hormonal turbulence finally settles.
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And notice the word settles.
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Again, stability may matter.
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During perimenopause, the hormones fluctuate dramatically.
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After menopause, estrogen remains much lower, but generally becomes more stable.
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Migraine does not disappear in everyone, and people with chronic migraine may continue
[11:53]
having substantial symptoms.
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But several reviews describe improvement after spontaneous menopause for a significant proportion
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So in other words, perimenopause can sometimes be the storm before calmer hormonal weather.
[12:07]
So I'm reminded of a woman I met in New Zealand.
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It was around 2019, maybe 2020 maximum.
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And she had been told that her migraines would improve when she reached menopause.
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And she was so desperate for relief that she underwent artificial menopause.
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So she underwent surgery to remove her uterus and her ovaries in the hope of decreasing
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And then we worked together and we achieved that.
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But that case stayed with me because it showed me how far people are willing to go to escape
[12:37]
migraine and how desperate and vulnerable they are.
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And so I always add a word of caution when we talk about averages and statistics, which
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You're not a statistic, you know, you are a hundred percent of yourself.
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And so being told to simply wait for the storm to pass can be incredibly painful when that
[12:55]
promise never comes.
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What about menopausal hormone therapy?
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So this is where individualized medical care becomes extremely important and really professional
[13:06]
There's no universal rule saying menopausal hormone therapy cures migraine or causes migraine.
[13:11]
Its effects vary, quite honestly.
[13:14]
Delivery methods matters.
[13:16]
Whether hormones are continuous or cyclical matters.
[13:19]
And whether you are having migraine with or without matters.
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Your cardiovascular risk factors matter.
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And the reason you are considering hormone treatment matters.
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Current reviews generally suggest that when menopausal hormone therapy is appropriate,
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maintaining more stable hormone exposure may be better tolerated by some people with migraine
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than producing repeated hormonal peaks and troughs.
[13:42]
Transdermal estrogen, therefore estrogen delivered through the skin, is often discussed
[13:47]
a bit more because it can provide steadier hormone levels than some oral regimens.
[13:52]
But this is absolutely an area to discuss with a clinician who understands both menopause
[13:57]
and migraine, particularly if you experience migraine with aura or have cardiovascular
[14:03]
Migraine with aura carries additional vascular considerations, so hormonal decisions should
[14:07]
never be based just on a podcast or what works for a friend.
[14:12]
Migraine is complex, it's not random, but you are unique.
[14:15]
And look, I've seen hormone therapy do wonders for some women, sometimes completely changing
[14:20]
their quality of life, but also sometimes creating much, much damage.
[14:25]
And so, so much depends on finding the right type and the right dose for you.
[14:29]
And also, remember what worked beautifully a couple of years ago may need a solid adjustment
[14:36]
So try to keep the dialogue open with your clinician and report anything that feels wrong.
[14:40]
Also, please consult with people who really know what they're talking about hormone-wise.
[14:45]
This is not a standard training for all doctors, so try to find people who are really specialized
[14:50]
Now, as you listen, I am well aware that for some of you, even getting one appointment
[14:57]
That can feel frustrating and infuriating and unfair, so that will be the object of
[15:03]
I'm really conscious.
[15:04]
It can be really problematic.
[15:05]
Now let's turn east.
[15:07]
Traditional Chinese medicine is going to look at this period of life through a very different lens.
[15:11]
And I want to make a distinction clearly before we explore it.
[15:14]
So concepts such as qi and yin, yang, liver energy and kidney essence, which we're going
[15:18]
to talk about, belong to a traditional Chinese medicine and medical framework.
[15:22]
They're not anatomical structures or measurable physiological mechanisms in the Western biomedical
[15:30]
They're also just translation of two languages that are very different from one to the other.
[15:34]
But traditional frameworks can still offer very useful ways of thinking about patterns,
[15:39]
rhythms, depletion and adaptation.
[15:42]
And it's very pragmatic too.
[15:43]
Perimenopause is, above all, a period of transition.
[15:47]
And traditional Chinese medicine has never viewed menopause simply as something going
[15:52]
It sees it as a change, a change of season.
[15:55]
There's an old Chinese philosophical idea that nature does not move in straight lines.
[15:59]
Day becomes night, summer becomes autumn, activity becomes rest, expansion becomes contraction.
[16:06]
And health comes partly from our ability to move with those transitions rather than demanding
[16:12]
that the body remain permanently in summer.
[16:15]
Now you might go, oh wow, this is autumn before winter, which is old age, that is so sad.
[16:22]
Well, that's not quite how TCM views it.
[16:25]
They see perimenopause as what they call a second spring.
[16:29]
And I'm not saying that lightly.
[16:31]
Spring is not necessarily calm.
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The weather changes quickly and temperatures rise and fall, storms appear unexpectedly,
[16:37]
and everything is reorganizing beneath the surface.
[16:41]
Perimenopause can feel much the same.
[16:43]
Hormones fluctuate, cycles become less predictable, and the body can temporarily feel more sensitive
[16:50]
But in Chinese medicine, this transition is not viewed simply as something being lost.
[16:55]
It is also a redirection of energy.
[16:58]
As the body gradually moves away from menstruation and reproduction, the resources once invested
[17:04]
there can begin to turn inward.
[17:07]
So perhaps perimenopause is not autumn after all.
[17:10]
It's the unsettled weather of a second spring, a different season of growth, of strength,
[17:16]
of wisdom, and of renewal.
[17:18]
It's interesting because I've just worked on the podcast of Patricia, and people tell
[17:23]
us they love podcasts with actual migrant heroes, and this is one of them.
[17:27]
And Patricia explains that renewal beautifully as she looks forward to her new and regained
[17:33]
life with much fewer migrants, regained independence and self-confidence and self-trust, and how
[17:39]
she wonders how she's going to be when she turns 80.
[17:42]
There's a beautiful illustration of this new spring.
[17:45]
These are not just words, you'll hear it from her.
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The next decade can be gorgeous and a prolific one, and you will see she wants you to give
[17:53]
hope, and I want that for you too.
[17:55]
She's a great example to follow, a great leader in her own right.
[17:59]
Now, in traditional Chinese medicine, the reproductive development and aging are closely
[18:04]
associated with what is called the kidney system.
[18:07]
And again, this does not mean your physical kidneys are failing.
[18:10]
It refers to a broader traditional concept which is associated with development, with
[18:15]
reproduction, resilience, and constitutional energy.
[18:18]
And as women move toward menopause, traditional practitioners often describe a gradual decline
[18:24]
in kidney yin, or kidney essence, and in simple language, you could think of yin as
[18:28]
representing the body's cooling, nourishing, moistening, and grounding qualities.
[18:34]
So what happens when that cooling and grounding capacity becomes relatively weaker?
[18:40]
Traditional Chinese medicine would expect more signs of internal heat or internal instability,
[18:46]
hot flashes, night sweats, restlessness, poor sleep, dryness, a feeling of being tired but
[18:53]
somehow unable to settle, and sometimes headache.
[18:56]
From a Western perspective, we would describe vasomotor symptoms, neuroendocrine changes,
[19:02]
and sleep disruption.
[19:03]
Traditional Chinese medicine uses a different language, less cooling, more apparent heat,
[19:08]
different map, some overlapping territory.
[19:10]
Now why migraine may feel more explosive?
[19:14]
So in traditional Chinese medicine, perinopause involves a second system, the liver system.
[19:19]
It talks about liver yang rising and liver qi stagnation, and again neither refers to
[19:25]
The traditional liver system is associated with keeping things moving smoothly, including
[19:30]
qi, emotions, and the body's response to change.
[19:33]
And so with prolonged stress, or poor sleep, emotional strain, hormonal fluctuations, or
[19:38]
depletion, that movement may become less free.
[19:41]
DCM describes this as liver qi stagnation, a kind of internal constraint, a kind of internal
[19:48]
Instead of the energy circulating smoothly, it begins to feel held, compressed, or stuck.
[19:54]
This can show up as neck and shoulder tension, irritability, a sense of pressure, sighing,
[19:59]
digestive disruption, or headaches that build with stress.
[20:02]
And when that constraint energy combines with deeper depletion, particularly declining yin,
[20:07]
another pattern may appear, which is called the liver yang rising pattern.
[20:11]
And the system has less anchoring and less capacity to regulate upward movement, so
[20:16]
pressure and activity rise more easily toward the head.
[20:19]
The traditional description can sound remarkably familiar.
[20:23]
Throbbing headache, pressure behind the eyes, dizziness, neck tension, irritability, sensitivity
[20:28]
to stimulation, and the sensation of heat or pressure rising upward.
[20:33]
I don't know if you relate to some of these symptoms, I hope you do.
[20:36]
Now there's a Chinese image that captures this beautifully.
[20:38]
When the root is weak, the branches shake.
[20:41]
So perimenopause can therefore be understood in TCM terms as involving both less smooth
[20:47]
movement below and more uncontrolled movement above.
[20:51]
Liver qi may become more constrained while depleted yin provides less anchoring for yang.
[20:58]
Western medicine might describe hormonal instability and disrupted sleep,
[21:02]
stress physiology, and a lower migraine threshold.
[21:05]
Traditional Chinese medicine uses a different language, but both are trying to describe a
[21:09]
system that has become less stable, less adaptable, and more easily pushed into an attack.
[21:15]
Now there's something super interesting in Western science that is not linked to
[21:19]
perimenopause on paper.
[21:20]
That happens in parallel at the same time and mirrors what traditional medicine is saying
[21:26]
And the science does not prove the connection, but the parallel is almost impossible to ignore.
[21:30]
So from a Western physiological perspective, the liver organ, it undergoes measurable,
[21:36]
structural, and functional changes with aging.
[21:39]
A review published in the World Journal of Gastroenterology in 2015 reported that liver
[21:46]
volume and hepatic blood flow gradually declined with age, with some estimates suggesting a
[21:51]
reduction in liver volume of approximately 1% per year from around 40, eventually contributing
[21:57]
to substantially lower liver volume in older adults.
[22:00]
Interestingly, the age at which this decline becomes more apparent broadly coincides with
[22:05]
the years in which many women enter perimenopause.
[22:08]
And by age 80, so much later when we're well into menopause, this could amount to roughly
[22:13]
a 30 to 35% reduction in liver volume compared with midlife.
[22:19]
And so current scientific evidence does not establish that perimenopause causes the reduction
[22:24]
For now, these should be understood as two biological processes that occur during an
[22:29]
overlapping period of life, with their precise relationship still requiring further
[22:35]
So you see, when traditional Chinese medicine talks about liver Qi stagnation, therefore
[22:39]
sometimes liver yang rising, it's not just metaphorical.
[22:42]
It's one of those beautiful spaces where we start to see overlap.
[22:46]
And so here, traditional Chinese medicine is going to take the change holistically and
[22:50]
not say, this is perimenopause and this is not, this is aging, and start to see the blend
[22:55]
and how both need to be addressed to help support that beautiful second spring.
[23:00]
And this is really important when it comes to migraine care.
[23:02]
Now the lesson is not to fight harder.
[23:05]
And this is where I think the Eastern perspective offers something particularly valuable.
[23:09]
Western culture often responds to midlife symptoms by saying, keep going and push through,
[23:14]
sleep later, work harder, drink more coffee, do everything you were doing at 35 while your
[23:20]
physiology is reorganizing itself underneath you.
[23:23]
Traditional Chinese philosophy would probably question that approach.
[23:26]
Here's a saying attributed to classical Chinese thought, a tree that cannot bend
[23:32]
eventually breaks.
[23:33]
Perimenopause may require more flexibility.
[23:36]
Your body may need greater consistency around sleep, more recovery after periods of intense
[23:41]
activity, more regular nourishment, more respect for heat, fatigue, and sensory overload.
[23:47]
Not because you're becoming weaker, but because your physiology is changing its operating
[23:53]
And rhythm matters.
[23:54]
Traditional Chinese medicine places tremendous value on rhythm, eating regularly, sleeping
[24:00]
at regular hours, matching activity with recovery, observing the seasons, noticing menstrual
[24:06]
patterns, watching what happens before symptoms rather than only reacting after they appear.
[24:11]
And this overlaps surprisingly well with modern migraine management.
[24:15]
Migraine brain often dislikes abrupt change, irregular sleep, sudden fasting, large changes
[24:22]
in caffeine, dehydration, rapid changes in stress, and perhaps in hormonally sensitive
[24:27]
people, rapid endocrine change.
[24:30]
So whether we speak in the Western language of migraine thresholds and nervous system
[24:34]
homeostasis or the Eastern language of balance and harmonious flow, we arrive at a similar
[24:40]
practical principle.
[24:42]
Reduce unnecessary volatility where you can.
[24:45]
And this is something I personally relate to.
[24:47]
I'm 43 now, and while my cycles are still quote-unquote normal, I can feel that my body
[24:52]
My digestion is not quite as forgiving as it used to be, and I have become a bit more
[24:57]
mindful of when I eat and the rhythms I keep.
[25:00]
Holidays are actually a good example.
[25:02]
When the usual routines disappear and meals become lighter, heavier, or simply less predictable,
[25:07]
I really feel disruption in my body.
[25:09]
I enjoy the holidays, of course, but I also find myself generally looking forward to back-to-school
[25:14]
time when life becomes more settled again, and I can return to a more natural flow, regularity,
[25:20]
And for me, that has been one of the clearest reminders that this stage of life is not necessarily
[25:25]
about something being wrong, but about realizing that my body may need a little more consistency
[25:30]
and attention than it once did.
[25:32]
It's subtle, but it's there.
[25:33]
I can't ignore it, and I long for it.
[25:35]
Now, what can you do today at home?
[25:37]
So here's your exercise for today.
[25:39]
Create what I call a migraine transition map.
[25:42]
So for the next few weeks, instead of tracking only whether you had a migraine, write down
[25:47]
five things each day.
[25:49]
Migraine symptoms, menstrual bleeding, sleep quality, hot flashes or night sweats, and
[25:56]
You can also note unusual stress or medication use.
[25:59]
Do not obsess over perfection.
[26:00]
The goal is simply to look for clusters.
[26:03]
Maybe attacks repeatedly follow two poor nights of sleep.
[26:06]
Maybe they appear around bleeding.
[26:08]
Maybe hot flash nights and migraine days travel together.
[26:11]
This information can turn my migraine or completely random into more insights that
[26:16]
you can make sense of.
[26:17]
And while your hormones may not be controllable from day to day, give your nervous system
[26:22]
as much predictability as you reasonably can.
[26:25]
Eat regularly, stay hydrated, protect your sleep schedule, avoid dramatic swings in
[26:30]
caffeine, and build short periods of recovery into your day.
[26:34]
If your migraine pattern has changed significantly, attacks have become much more frequent, and
[26:40]
you're considering hormonal treatment, bring that diary to a clinician who understands
[26:44]
migraine and menopause.
[26:46]
And of course, you can do all of that in the Migraine Heroes app.
[26:50]
Before you go, I'm holding a live session, Ask Diane Anything, Thursday, September 24th.
[26:57]
It's free, it's live, and it's exactly the place to bring whatever this episode
[27:01]
steered up for you, like why your migraine threshold can shift even when your labs look
[27:07]
Go to migraineheroes.com slash live.
[27:10]
That's migraineheroes.com slash live to save your spot.
[27:14]
Spots are limited, so don't wait until the day before.
[27:18]
That's all for today.
[27:19]
I hope this episode added another piece to your migraine puzzle.
[27:24]
If you'd like to apply what we've discussed to your own life, you can find us by searching
[27:28]
Migraine Heroes in the App Store or Google Play.
[27:32]
Look for the green icon with the love heart in the brain.
[27:35]
Migraine is complex.
[27:37]
But it's not random.
[27:38]
And every step forward brings us closer to lasting relief.
[27:41]
Your body has a story to tell.
[27:43]
Let's keep listening.
[27:45]
I will be back with you soon.
