Navigating the Migraine Chaos That Begins During Perimenopause

Day 4 (2026)

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Key Questions

How does hormonal activity during perimenopause affect migraine?
Why does migraine often worsen during perimenopause and sometimes improve after menopause?
How can an individual’s lifetime hormonal pattern — such as migraine during menstruation or pregnancy — inform migraine management during perimenopause and menopause?
How can you tell if symptoms like brain fog, sleep disruption, and anxiety are due to migraine or perimenopausal changes?
What is the main goal of hormone therapy for migraine during perimenopause, and which forms of administration are used?
How important is the timing of hormone therapy, and when is the optimal time to begin?
What is the significance of the FDA’s removal of the black box safety warning for hormone therapy for the migraine community?
What non-estrogen options are available for managing vasomotor symptoms and migraine when hormone therapy is not an option, such as in migraine with aura?
What strategies help patients seek effective treatment when providers themselves may not fully understand the interaction between migraine and hormonal transitions?
What practical steps can help prevent symptoms from being dismissed as a normal part of aging by healthcare providers?

Interview Notes

Treatments Mentioned

Antihypertensives
CGRP monoclonal antibodies (mAbs)
CGRP small-molecule antagonists (gepants)
Combined oral contraceptives
Diary (symptom tracking)
Diet
Hormone therapy (HT)
Hydration
Intrauterine devices (IUDs)
Oral estrogen (Premarin)
Progesterone-only contraceptives
Progestin-only pills
Propranolol
Sleep hygiene
Transdermal estrogen (patches and gels)
Triptans
Tubal ligation

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Disclaimer: The Migraine World Summit aims to bring you a variety of perspectives and expertise, free from bias or judgment. Alternative theories presented in this video have not been medically reviewed. Views expressed in this interview do not necessarily represent the views of the Migraine World Summit. Please always consult your health care professional and do your own research before making changes to your treatment plan. Captions are auto-generated and may contain errors.

Expert

Jan Lewis Brandes, MD

Assistant Clinical Professor of Neurology | Founder
Vanderbilt University | Nashville Neuroscience Group

Jan Lewis Brandes, MD, MS, holds an appointment as an assistant clinical professor in the Department of Neurology, Vanderbilt University School of Medicine, and is the founder and director of the Nashville Neuroscience Group, both in Nashville, Tennessee. After finishing her medical degree at Vanderbilt University School of Medicine, she completed her postgraduate education in neurology, serving as chief resident. Her earlier graduate work centered on molecular virology, as a Fulbright Scholar at the Robert Koch Institute of Virology, Free University of Berlin, and at the University of Tennessee, Knoxville, where she earned a master’s degree in microbiology. She holds board certification from the American Board of Psychiatry and Neurology and has been UCNS-certified in headache medicine.

Dr. Brandes has served as the principal or co-principal investigator in more than 100 clinical trials for headache management. She has authored more than 150 publications in peer-reviewed journals, and her most recent focus has been on expanding enrollment in pregnancy registries, particularly those related to the use of CGRP monoclonal antibodies during pregnancy, and in education regarding hormonal management of migraine.

Dr. Brandes served on the board of directors of the National Headache Foundation for more than a decade, where she was involved in educational programming and patient advocacy. She is a past fellow of the Academy of Neurology, and of the American Headache Society, where she served on the board of directors. She also is the past president of the American Council for Headache Education.