Perimenopause marks a time of change in a woman's hormonal environment, which is apparent from the resultant irregular periods and vasomotor symptoms. These symptoms can start in the early 40s and continue through to the early 50s. Migraine is also affected by hormonal fluctuations, particularly the natural decline in estrogen in the late luteal phase of the menstrual cycle. This effect of estrogen "withdrawal" on migraine appears to become more predominant during perimenopause. Despite the increased prevalence of headache and migraine in women in their 40s, migraine is underdiagnosed in this population. In women attending with symptoms suggestive of perimenopause, it is important to ask about headache symptoms. Once diagnosed, a number of strategies can be used to manage both perimenopausal migraine and menopausal symptoms effectively, with the potential to reduce the associated morbidity.