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Podcast Episode 15: Migraine and menopause with Dr Katy Munro

Podcast Episode 15: Migraine and menopause with Dr Katy Munro

On this episode of the Newson Health Menopause Society Podcast, host Lauren Redfern is joined by Headache Specialist at the National Migraine Centre, Dr Katy Munro. Having developed migraine in her 40s around the time of the perimenopause, Katy became involved with the National Migraine Centre, first as a patient and then subsequently, as a doctor. Katy now works as a GP and Headache Specialist at the National Migraine Centre. She helps patients find symptom relief by developing holistic treatment programmes in order to address the multiple factors that may be implicating migraine attacks. Dispelling stigma around migraine as simply a ‘bad headache’, Katy explains the complex ways in which migraine can be linked to a genetic predisposition and worsened by factors such as fluctuating hormone levels. Katy also highlights that migraine should not be thought of as a ‘symptom’ but rather, a condition itself. Helping to outline current effective treatment options, Katy breaks down a complicated and at times elusive condition accessibly.

Katy has recently written a book called ‘Managing Your Migraine’ which is available to buy, you can get your copy here. You can keep up to date with Katy’s work by following her on Twitter @katymunro1 and on Instagram @migrainedoc. You should also listen to the Heads-Up Podcast which can be found on Spotify and Apple Podcasts.

Katy’s National Migraine Centre can be found on social media via Twitter @NatMigraineCtr, IG @national_migraine_centre 

Episode Transcript:

Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multidisciplinary collective of interested professionals passionate about improving hormone health across the world. The society exists to educate and inspire others to raise the standard of menopause care and access to treatment, to facilitate research, collaborations across specialties and countries, and to provide expert advice and guidance to our associates. The ultimate aim of the Newson Health Menopause Society is to improve the lives and future health of women and all who experience the perimenopause and menopause. I’m Lauren Redfern. I’m a medical anthropologist and I’ve been exploring the experiences of those using testosterone as part of their HRT treatment. In this podcast series, I’m going to be talking to guests from a variety of different disciplines in order to share knowledge and ultimately improve our understanding of the perimenopause and menopause.

Lauren Redfern [00:01:02] Anyone who has ever been unfortunate enough to suffer with migraines will be able to tell you that the debilitating experience is not something they would wish upon their worst enemy. Whilst for some, migraine attacks can be few and far between, for others, their consistent reoccurrence can be life altering. Far from just an inconvenient headache, migraines can interfere with a person’s ability to work, to maintain a social life, and ultimately to live a normal day to day existence. At the most incapacitating of times, migraine sufferers can experience attacks nearly every day, making employment and living a pain free existence almost unimaginable. Increasingly, we’re recognising that the symptoms of migraines can be exacerbated by a number of triggers such as diet, alcohol consumption and stress. Whilst we may be able to make reasonable life adjustments to address some of these triggers, others can prove a little more challenging to deal with. Fluctuations in our hormone levels, for example, whilst known to impact migraine severity and occurrence, can still be difficult to control. This can evidently mean that during times in our lives, such as during the perimenopause and menopause, when our hormone levels are dropping, migraine attacks and severity can worsen for many. Here to talk with me today about the fascinating topic of migraine and its management is GP and headache specialist at the National Migraine Centre, Dr Katy Munro. Hi, Katy, could I just ask that we start with you introducing yourself to those listening and telling us a little bit more about the work that you do.

Dr Katy Munro [00:02:37] Hi Lauren, and thank you so much for inviting me. I’m always happy to talk about migraine because there’s so many people out there that don’t really understand it and could do with that advice on managing it. So I got into managing migraine partly through trying to manage my own migraine, which really reared its head, excuse the pun, during perimenopause. I was a GP at the time and didn’t know very much about migraine until I started getting recurrent horrible headaches. So I went on a journey of finding out about it and ultimately ended up working as a GP headache specialist for the National Migraine Charity. We are a charity that’s been around for over 40 years, set up to support and help anybody who needs advice on management of their migraine. And so it’s an open access service. People can just refer themselves by filling in our online booking form on our website. And then we have a big team of specially trained headache specialist doctors who will do a consultation with them. We ask for a voluntary donation because as a charity we don’t have any link with the NHS, we don’t get any funding, so we’re very reliant on donations. But we have a very, very good set of headache specialist doctors who are delighted to see people with migraine of any age.

Lauren Redfern [00:03:55] And obviously you help run the National Migraine Centre. Could you tell us a bit about what that involves and also what prompted you to dedicate your time to working at the centre as opposed to, as you say, in the NHS?

Dr Katy Munro [00:04:07] So I was a partner in the NHS for many years and back in 2013 I decided to slightly change my emphasis. I’d really become interested in migraine and chronic pain myself, and also I was a mental health specialist and many people with migraine have mental health issues. Anxiety is very common. I decided that I would work and dedicate pretty much all my time now to the National Migraine Centre because I see such a need for good education and the relief when people understand migraine, get a plan, individualised plan for themselves, the relief on their faces and the rewards of getting that right are so huge. And, you know, we have everybody from – I had a three year old the other day up to sort of people in their seventies and eighties. But the majority of our patients are women in the perimenopause years. So in between sort of forty and late fifties who have so many other life challenges. So they may be working, they may be looking after children who might be coming into teen age with all the joy and delight that brings. Changes, lots of changes for teenagers. And they may have elderly parents, they may have all sorts of things going on. So I think it’s one of the areas… traditionally migraine has been thought of as being, ‘Well, just it’s a bad headache, isn’t it?’ And fighting that stigma I think is really important to me. So I prefer to talk about migraine as a primary headache disorder, which gives migraine attacks. And migraine attacks may lead to headache, nausea, vomiting, dizziness, fatigue, word finding difficulties, brain fog, even sometimes tingling or paralysis on one side of the body and so many other symptoms. And I think there’s a huge amount of ignorance about that out there. So that’s where I started from really. And one of the things that we’ve done, at the National Migraine Centre, is try and raise awareness and education in many ways. So we have factsheets on our website and we have a podcast called Heads Up, which I started with some of the team and that’s been going since 2019 now. And I’ve also written a book called Managing Your Migraine, which is out, Penguin commissioned that. So that’s been another way of getting information out there. And I think people are thirsty for information. I know I was before I fully understood it well.

Lauren Redfern [00:06:43] And I was going to ask you, but you sort of addressed that pretty well. But I mean, in my introduction, I spoke a bit about how actually migraine is intensely debilitating for those struggling with their condition and that this idea of it just being a bad headache is really problematic, actually, because it’s not reflective of what people experience in that. And I wondered for those listening that may not be familiar with migraine, how it presents, how it differs from, say, a headache, whether you could explain a little bit more about the specific condition of migraine and how it affects those afflicted?

Dr Katy Munro [00:07:16] Definitely. I think there’s a misconception that you have to have a really severe headache for it to be counted as a migraine. So actually, to clarify, migraine is a spectrum disorder so you can suffer attacks very rarely – they may occur maybe once or twice in your lifetime – or right at the other end of the spectrum, we see patients with chronic migraine who are having debilitating headaches and other symptoms every single day of their lives. And that can go on for years and that can totally impact on their work lives, their social lives and family interactions. They can’t plan things. So I think of it as a spectrum disorder. That’s the first thing. So a headache is a symptom. So people say to me, ‘Oh, I just get the normal headaches.’ And I say, ‘There’s no such thing as a normal headache.’ You would not say to me, ‘I just get the normal rashes’ because people want to find out why they got this rash. And in the same way, they should be curious if they’re having headaches, because there’s always a reason behind why somebody has a headache. And it’s not just a normal thing. Some people never get headaches. I met somebody yesterday and he said, ‘Never had a headache in my life’, So…

Lauren Redfern [00:08:29] Oh my god the dream. Can you imagine.

Dr Katy Munro [00:08:30] Yeah. So the headaches are just one part of migraine, the primary headache disorder. I think the other thing I would like to emphasise, which is often a surprise to people, is that migraine is a genetic disorder. So I have a little mantra. Migraine is a genetic, neurological, whole-body condition. I’ve extended it recently, so it’s quite a mouthful. But just to break it down, migraine is a genetic condition. We know there’s at least 40 genes involved in the hereditary processes involved in migraine. So often people can point to somebody in their family and say, ‘Oh, yes, my auntie had it, or my mum or my siblings or my grandmother.’ Sometimes they can’t. But some researchers a while ago looked into that and they spoke to people and said, ‘Do you have a family history?’ And then they hunted down all the relatives of those people who said no and asked all the relatives, ‘Do any of you get migraine or migraine like headaches?’ And the answer was yes, an awful lot of them did, but they just hadn’t labelled it or told anybody. So there’s often a family history. So the genes for migraine set the brain to be always a little bit more sensitive to change. And I think that’s a key message because if you understand that, then you understand why changes during your life can make the difference as to whether or not you have migraine attacks. So changes can be internal body changes like fluctuating blood sugar, poor sleep, stress, hormones obviously, or it could be external environmental factors and sometimes people are sensitive to the weather. So falling barometric pressure or things like light glare or flicker. So I know a lot of patients say, ‘Well, if I’m in the car and the sun is flickering through the trees, especially in the autumn, sunlight is quite low. That’s going to make my brain feel really irritable.’ And then they get a migraine attack afterwards. So it’s not a simple thing to just say, ‘Oh, it’s genetic, so you’re definitely going to get it.’ It’s genetic. But epigenetic factors, these environmental things make the difference as to whether you have a period of attacks. And then we find that throughout a person’s life it can fluctuate in severity and frequency. So I see quite a lot of teenagers who are having growth spurts and so they tend to get more migraine attacks and then as the growth spurt settles down and as they go out of teenage, things settle, their hormones settle, maybe they’ve gone through that stressful period of GCSEs and A-levels and changing, you know, lots of changes for teenagers too. So yeah, it’s more complicated than just saying, ‘Oh, it’s just a bad headache,’ isn’t it?

Lauren Redfern [00:11:27] Well, it’s interesting because you mentioned previously how migraine can be worsened by overall change. And obviously I think that’s really important to think about in the context of perimenopause and menopause when changes to women’s hormones are occurring. And I wondered if you could talk us through a little bit more about how and why migraine maybe affected or triggered during this time. So really what’s happening in the body and why that affects the severity of migraine.

Dr Katy Munro [00:11:55] So we know one of the hormones that’s implicated in migraine attacks is estrogen. And we see the importance of estrogen throughout reproductive life, really, because we know that women quite often complain that they have worsening migraine attacks around their menstrual cycles and that is because of the falling level of estrogen at the end of the month. So that is one of the ways that estrogen affects women. The other thing is women who get migraine with aura tend to get a more irritable brain when their estrogen levels are high. And so just to say what aura is, aura is defined as neurological changes which come and go within the hour before the headache phase starts. So only about 25% of people with migraine get aura. But those that do will often have visual changes. So blurred vision or zigzags, they sometimes draw a zigzag line in the air when they’re describing it, maybe sparkly lights, sometimes patches of blind spots. And so we see women going through pregnancy who have aura, have higher levels of estrogen that make an aggravation of their migraine. And when they’re going through pregnancy, if they don’t have aura, their estrogen is nice and stable. So comes the perimenopause, which of course we know now can start, you know, even ten years before the actual cessation of periods, the estrogen levels start to fluctuate quite wildly, a bit like a roller coaster. So it may be, rather than having that nice regular 28-day cycle with a drop in estrogen at the end of the month and triggering a migraine attack, suddenly estrogen levels are all over the place. So women who have migraine without aura tend to find that their attacks are triggered more intensely, and women with aura may find worsening of attacks because sometimes estrogen is zooming up again. So it’s really that fluctuation. There are other factors, of course, in those years, as I’ve kind of briefly mentioned earlier, because it’s other things changing as well in a woman’s life and that can be really tricky. But I think the role of estrogen is really important. Other hormones, of course, are changing in the perimenopause, so progesterone and testosterone are both changing. But the research at the moment is more around the role of estrogen. There is some evidence that maybe testosterone is implicated, but it seems to be the estrogen that’s the key one.

Lauren Redfern [00:14:29] And can I ask on that? So something I think can be somewhat confusing for some of the women I’ve spoken to is if they have had migraine and particularly migraine with aura, they may have been told for the majority of their lives that they can’t use oral contraceptive pills as a consequence of struggling with migraine, but that in fact HRT can be used safely, well body identical HRT. And I wondered if you could talk us through why this is and what the differences are between body identical HRT and, say, the estrogen oral contraceptive pill and why HRT might be safe, but the pill not so safe for people with migraine.

Dr Katy Munro [00:15:08] That’s a really important question. And it’s very important in women of reproductive age who have aura, because we know that having migraine with aura is an independent risk factor for having a stroke. So if you add in extra estrogen, and bearing in mind that contraception increases your natural level of estrogen, there are two factors there that could contribute to your risk of a stroke. It’s only a small increased risk, but it’s enough to place oral contraceptives with estrogen as what we call the UKMEC 4, which is a contraindication for women with migraine with aura. Women without aura can take those kind of contraceptive pills with no problem. But once we come into the perimenopause, we know that we are adding back natural estrogen to try and replace the estrogen that would have been there anyway. We also know that transdermal estrogen preparations like gels, patches or sprays have no increased risk of clotting through venous thromboembolism. And so they’re not going to raise the risk of stroke. So it’s absolutely fine for women with migraine to be taking estrogen as HRT – as well as all other things are equal – but what we would always strongly recommend is that they use the transdermal preparations. The other reason is that if you were taking a tablet preparation, you are having to take a much higher dose of estrogen because it has to pass through the liver. And also, you’re getting more swinging levels of estrogen on a daily basis, whereas transdermal preparations are absorbed very smoothly. And so you get a nice, even blood estrogen level.

Lauren Redfern [00:16:57] I mean, it’s so interesting to note that as well that it’s the replacing of what’s already being lost. So that’s, I think, really useful to stress. So obviously we’ve discussed and I mentioned in the introduction, as I said, how symptoms of migraine can be very debilitating and make leading a normal life very challenging. But you mentioned earlier and I thought it’s important to touch back on, that there still seems to be a level of stigma associated with migraine. And I just wondered what your thoughts were regarding why you think stigma continues to persist around migraine? Because I know that when we spoke prior to this recording, you told me you sometimes see patients, that it’s almost every day of the month that they can count their good days on one hand. And yeah, I’m curious as to why, you know, this stigma is sort of persisting around it and what your thoughts are.

Dr Katy Munro [00:17:42] I think there’s a number of reasons. I think historically migraine was stigmatised. I think that started back in Victorian times when migraine was considered to be, if you were male, it was a sign that you were very academic or rather cerebral and bright. But if you were female, it was considered that you were rather histrionic and a bit flaky and pathetic. And I think women were treated like that for many years, and I think that underpins some of the stigma today. I think the myth that migraine is just a headache also, and then the perception that if somebody says that they can’t come to work because they’re having a migraine attack, they’re probably swinging the lead and they’re probably faking it because there’s a misunderstanding of the impact because of this, ‘Oh isn’t it just a normal headache? So everybody gets headaches.’ But of course, you know, in a severe migraine attack, the person is going to be lying still, lying in a dark room, they can’t think straight, they may not be able to speak properly because they can’t find the words, they have this absolutely horrible pain in their head that is worse when they move and, you know, getting up and going off and doing whatever they’re supposed to be doing, picking up the kids or going to work or giving a presentation just is not possible. And I think that the other thing about migraine is it doesn’t kill you. It doesn’t tug at the heart strings. And so it feels that people with migraine are often dismissed and that pervades the whole of society and also has implications for funding of migraine research and migraine treatments. And we’re seeing this at the moment with the new migraine treatments, the monoclonal antibody injections, which are licenced, which are approved by NICE, which should be available on the NHS. And there’s a massive postcode lottery for whether patients are finding access because it’s not fully funded. When you think about migraine as a common condition, one in seven people get migraine, three times as many women as men, and it’s just not taken seriously enough, in my opinion. I know many people who have had to change their careers because of having migraine. They’ve either had to reduce their hours or turn down promotions or even resigned their career pathway and, you know, stopped working because of the impact of migraine on them. That’s partly why I’m so passionate to help people, because it doesn’t have to be like this. You know so much can be done to help.

Lauren Redfern [00:20:25] Yeah. And I’m curious, you mentioned previously there, sort of the new treatments that are coming forward and I want to ensure that we do sort of speak briefly about actually what people can do to treat migraine. So obviously, I know when we spoke, you said that you are quite overrun with waiting lists of patients. And obviously I think people can get frustrated when going to a GP to try and find, you know, the right course of treatment for them. It would be great to just have a quick chat about what people can do because I know that we’ve spoken about the importance of a holistic approach when it comes to treating migraine, but what in essence that means and what factors can be considered alongside medication and what the medications are.

Dr Katy Munro [00:21:06] Yeah, so this podcast may go on for about a week and a half now that you’ve asked me that question Lauren. So basically, I think about migraine management very much holistically. It’s not about finding the one thing that will be magically the answer for your migraine attacks. It’s about looking at all the little things that you may be able to control that will reduce the change that your brain has to deal with. So that starts off initially by lifestyle factors. This is a very simple thing that people can do, which they often haven’t been told about or don’t realise the importance of. So first of all, I always talk about diet and about frequency of eating. Your brain likes a nice, even blood sugar level. Thank you very much. So if you are skipping meals or if you’re going off to exercise first thing in the morning, you haven’t had anything to eat since dinner the night before or if you are having long gaps in the day, and this is partly why I used to get migraine, because as GP’s you very rarely get lunch. So eating regularly is very important. So we advise people to eat something, certainly not to skip breakfast, but to have something then throughout the day, every 3 to 4 hours and probably even a bedtime snack. But also it’s important not to eat too much quick-release carbohydrates. So quick-release carbohydrates give you a spike in your blood sugar and then your insulin pulls that down and then you get a crash. And so slow-release energy foods like complex carbohydrates, whole grains, that kind of thing. Healthy fats and protein are the things to have for your snacks. The other thing is we know that a good level of Omega 3 may be helpful in preventing migraine, so eat lots of oily fish. Or if you’re vegan, then Omega 3 supplements might be useful. And then we talk about the importance of routine in terms of sleep. So going to bed at the same time, waking at the same time and having good quality sleep is really important. But there are things people can do to work on that. We’ve done a whole podcast episode on migraine and sleep, giving tips about that. And then it’s things like trying to do mild to moderate regular exercise. We know that high intensity exercise may aggravate and that any exercise aggravates the neck and shoulders because there’s a bidirectional relationship between the brain and the neck and shoulders. So the neck and shoulders can give pain signals to the brain and trigger a migraine attack and vice versa. A migraine attack can be felt in the neck and shoulders. We then often move on to kind of supplements. So there are some, there are some quite good evidence for certain supplements like magnesium, vitamin B2 and Coenzyme Q10. And I’m always encouraging people to have vitamin D, make sure your vitamin D is optimised, because in this cloudy country, it’s a very common to have a low vitamin D. And then I talk to people about the next two headings. So that’s basically how to manage your acute treatment, so your acute attack, need to have the right medication in the right dose, in the right place to be rapidly absorbed and at the right time. Also, when your attack is beginning is the time to hit it, not waiting until it’s really, really bad. And there’s lots to talk about around that. The three things that seem to be important for treating acute attacks is something to move the stomach contents on. So an anti-nausea, anti-sickness tablet is really helpful and often hasn’t been offered and patients can take that even if they don’t feel sick because we know that gastric stasis is very common at the onset of an attack. Then something like a non-steroidal, which means things like ibuprofen or naproxen or even good old aspirin. Obviously if people are listening, they need to just be sure that they can take those safely if they haven’t got any gastric irritation or risk of ulceration of the stomach or allergies, obviously. And then the third thing is a tryptophan and triptans can really make a difference. There are several different named triptans that are all available on the NHS and many people have never heard that. I even asked a whole group of GPs the other day, ‘How many triptans can you prescribe?’ And they could only name three. There are seven. So most people start on sumatriptan and it’s really important, I think, to let people know that if that doesn’t suit them, try a different one. It’s a very individual thing. And they come in different formulations, they may come in tablets or dissolving on the tongue formulations like mouth wafers or nasal sprays, or injection – sumatriptan comes in the injection. We rarely prescribe that because the melts and the nasal sprays are really good. And then the third heading, so we’ve had lifestyle and supplements, acute treatment, and then I start to talk about prevention, the more medical interventions of prevention. And that would be under the headings of medications, neuromodulation devices and injectable therapies. So the medications, most of the medications we use to prevent migraine have been around, been used for other things. So they may have been used as antidepressants like amitriptyline. They may have been used for blood pressure like propranolol or candesartan or they may have been used as antiepileptic like topiramate. And these have got good evidence and we use them quite frequently. They need to be used in a high enough dose for long enough. So we always say to people, try and get to your maximum tolerated dose and stay on it for at least three months before you can judge whether that’s the right one for you. And often people haven’t realised that and they’ll say, ‘Oh I tried amitriptyline ten milligrams for a couple of weeks and it didn’t work’. So you have to be patient and keep trying. And so the annoying thing is we can’t look at a patient or do a test and say, ‘Oh, this’ll be the one for you.’ So that’s really frustrating. And so we have to say, ‘Well try this one’ and, ‘Oh, that didn’t work or that had side effects. Okay, try this one.’ And it’s a slow and slightly frustrating process, but worth it if you find the right one for you, because suddenly your migraine attacks have diminished, hopefully by at least 50%. So the medications are useful and obviously often prescribed by GPs. The neuromodulation devices are a really interesting, exciting new area. Some of them have been around for a while, but there are new ones coming and the one we quite commonly speak about is the CEFALY® DUAL, which you stick on your forehead, it’s like a little diamond shaped machine, a bit like a TENS machine, that little. And you press the buttons and it gives you little electrical impulses in your forehead, not something to wear around a supermarket, because you know, people might think you just landed in your space machine from another planet, but sitting quietly in a chair and using that for 20 minutes each day can be used as prevention, but also that one can be used for an hour at the onset of an attack. So you can use that for acute treatment as well. And then there are things like the Nerivio™ which is available in the States. You stick it on your arm and it sends electrical impulses through the peripheral nerves up to the brain. So that may be available soon. And there’s another one called Relivion®, which goes like a band around the whole head. And there’s another one called the sTMS mini™, which gives magnetic pulses to the back of the brain. But that one’s expensive and quite tricky to get hold of. So that’s an interesting area and often people are quite relieved that there’s something they can try which isn’t swallowing another tablet.

Lauren Redfern [00:29:08] Yeah, absolutely.

Dr Katy Munro [00:29:09] And then the third area is injections. And here we have the great occipital nerve blocks which we can do one each side of the back of the head with a steroid and an anaesthetic and that can be useful. Or you may have come across Botox for use in migraine. So women who are getting cosmetic Botox a few decades ago suddenly realised that their migraine attacks were diminishing and then studies were done and it was found that Botox mutes down the sensory impulses from the nerves that generate some people’s migraine attacks. And Botox can be really helpful. And then the new kids on the block are the new monoclonal antibody injections. So these are CGRP blockers. So CGRP is one of the pain neurochemicals, it’s called calcitonin gene related peptide and there are others that are implicated in attacks. But this seems to be one of the key ones. And by blocking that, we are hearing the words ‘life changing’ from some people with migraine. So particularly using it for people with chronic migraine. And you know, I have people coming back and saying, ‘I can’t believe how much better my migraine attacks are.’ And they give the injections to themselves once a month and usually it works pretty quickly and usually they get very few side effects. So it’s really wonderful to have new developments and in the future there will be probably, CGRP blocking medications that we will be able to prescribe as tablets, which is even better. So yeah, so much, so much to talk about.

Lauren Redfern [00:30:51] One thing I wanted to ask you that I heard you mention before this podcast is sort of a wariness that needs to be taken around the use of codeine or co-codamol when it comes to migraine relief. So I know for myself as a migraine sufferer, the packet of Migraleve that is often behind the pharmacist, you know, counter. It’s got your pink and your yellow pills and it can work to great effect. But I know that when I’ve spoken to you prior, you have said, take care, take care with that. So I just wondered if we could spend a little bit of time just chatting about that.

Dr Katy Munro [00:31:26] Yes, ideally, I would say try and avoid codeine at all. Codeine is still available in combination products such as the one you mentioned and other things, and is sometimes prescribed for migraine especially, tends to be the casualties. People think, ‘Oh, it’s a big headache, it needs a big painkiller.’ Unfortunately, codeine is a disaster for people with migraine if they take it more regularly. So if you take it once a year, I won’t fret too much. But unfortunately, the way that it blocks pain isn’t ideal for the type of pain that’s generated in migraine attacks. It aggravates gastric stasis, so it tends to make people feel more nauseated and reduce the absorption of the medications that could actually help better. It puts people off to sleep and often they go off to sleep and then they wake up and think, ‘Oh, my migraine’s been so helped by that codeine. But it’s probably just that they fell asleep in the migraine attack.’ And the other big problem, of course, with codeine is it is addictive. So we find that it can improve the acute pain in certain… briefly, but if you take it more regularly, it stimulates the pathways that generate chronic pain. So it’s much more likely to give people what we call medication overuse headache. So it actually, although it seems to help, in the longer term it is going to really raise the risk of you having chronic daily headache. And because of its addictive nature, people get on to higher and higher doses because it’s not working so well. And then we try and get people to reduce the codeine. If they’re on high doses, do it very gently, if they’re taking it just occasionally and don’t, get better advice, switch onto something better. But if you reduce and stop codeine, the chronic daily headache that that has produced can take several months to disappear. It does tend to disappear and is worth doing. But the other thing is it stops the things working so well that would have been more effective for that migraine attacks. So, no headache specialists are fans of codeine.

Lauren Redfern [00:33:45] No thanks for clarifying. I wanted to ask just briefly for any healthcare professionals listening that could be interested in learning more about treating patients with migraine, specifically during the perimenopause and menopause, whether you had any advice really of things they could look at or resources. I know there’s your book that you’ve written about managing migraine.

Dr Katy Munro [00:34:04] Yes. So my book has a whole chapter on migraine and hormones. It has chapters on all the kind of topics that we’ve touched on, really. We also have two episodes on hormones and migraine as part of the Heads Up podcast, one of them is with Professor Allan McGregor, who is a leading researcher in women’s health, HRT and migraine and world authority and the other episode is with Dr Louise Newson. The Newson Health podcast I think, and Louise’s podcast are really good sources of information. I’m always recommending the balance app to patients to track their symptoms of the perimenopause. And I think the other thing that GPs need to know about if they don’t already, is the FourteenFish ‘Confidence in Menopause’ prescribing. So I think as headache specialists we also have to be perimenopause specialists because we see the overlap in these conditions so much. You know, when you think about the symptoms of the perimenopause, so many of them also occur with migraine. So we see fatigue, we see brain fog, we see insomnia, we see anxiety and depression, you know, and I think it’s almost compulsory on us to be asking the question when we’re doing a headache consultation and saying, ‘What’s happening in your cycle? What’s happening to your periods? Are you getting any symptoms of the perimenopause?’ and tackling that. And so yeah, I would urge GPs to really get up to speed on both because you know, you can’t really treat the marypen… The perimenopause, the marypenipause I nearly said that’s…

Lauren Redfern [00:35:42] I’m going to use that spoonerism again the marypenipause. That’s great.

Dr Katy Munro [00:35:46] The perimenopause, you can’t treat it and ignore the women who have headaches during the perimenopause. And it rather grinds my gears. I went to a talk on the menopause yesterday and the consultant who gave an excellent talk used the term of migraine as a symptom. And I am like, oh. Worsening headaches is a symptom. And the underlying cause is probably that they have had the genetic background of migraine, but the change in estrogen levels has triggered the migraine to become more obvious, and that’s certainly what happens in quite a lot of women. So I think we need to be flagging up that migraine is a disorder that becomes more obvious in the perimenopause – is not caused by the perimenopause. It is triggered to be more obvious.

Lauren Redfern [00:36:34] Absolutely. I think sadly, that’s all the time we’ve got today, Katy, to chat about this. And it’s a shame because I just feel like I could talk for hours about this. Just keep going, you know? And you said it’s going to be a however many hour podcast and I think we could keep going.

Dr Katy Munro [00:36:47] There’s a lot to say.

Lauren Redfern [00:36:48] Exactly. And I like to end each of these podcasts by asking those that have joined me whether they have any take home messages that they’d like to stress to anybody listening. So I just wonder, yeah. What would your take home message be around this topic?

Dr Katy Munro [00:37:00] Yeah, I think the take home messages are don’t ignore headaches and think that they’re just normal. Don’t assume that your mild but quite debilitating headaches are the whole picture and ask the question, ‘Is this migraine?’ Because if … sometimes people say, ‘My most bothersome symptom is the brain fog or the fatigue’, and they think they can’t go and ask about that. So the second thing is find out good information about migraine and that may involve asking at your GP surgery, ‘Is there a GP that gets migraine?’ Because they tend to know a bit more about it. Or if you’re going to be referred to more specialist advice, ‘Am I being referred to a headache specialist?’ Because I think, you know, it isn’t difficult to get good advice once you find somebody who understands about migraines. But if you find somebody who hasn’t really got up to speed on all of the things we’ve discussed today, then sadly still we’re hearing people are getting given not great advice and they’re not given enough advice to manage their own condition. And then the final message really is there is hope, don’t put up with it. There’s so many things that we can do. I normally end consultations by saying ‘this is only plan A, there’s always a plan B, you will not have tried everything’. And people often say to me, ‘I’ve tried everything’. They never have. They’ve never tried everything. And so don’t give up and don’t let it sink you because there’s so much that can be done.

Lauren Redfern [00:38:37] That’s great. Thank you so much, Katy. And for those listening who’d like to know more, obviously Katy, as she mentioned, has written a book that you can purchase called ‘Managing Your Migraine’ and does also host a brilliant podcast, Heads Up. So be sure to give that a listen. Thank you so much, Katy, and I’ll speak to you soon.

Dr Katy Munro [00:38:51] Thank you for the invitation.

Lauren Redfern [00:38:55] We would love for you to join our collective of professionals passionate about the menopause. Visit to become an associate. You’ll receive regular webinars and advice from our experts, as well as opportunities to network and connect with the latest research from around the world. You can follow us on Twitter @NHMenopauseSociety and don’t forget to tell your colleagues about the Newson Health Menopause Society.


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