Background <p>Studies about perimenopausal migraine are limited. In this study, we aimed to explore the characteristics of perimenopausal migraine and to compare perimenopausal women with and without migraine in terms of the levels of Estradiol and Follicle-Stimulating Hormone (FSH). We also aimed to correlate migraine severity scores with Estradiol and FSH levels.</p> Methods <p>A case-control study of 66 subjects divided as Group 1 (<i>n</i> = 22): migraine onset during perimenopause, Group 2 (<i>n</i> = 22) migraine onset before perimenopause, and Group 3 (<i>n</i> = 22) age-matched healthy controls. Perimenopausal women with any type of migraine (age 40–55 years) were eligible. We excluded secondary and other primary headaches, hormonal therapy and chronic illness. Subjects underwent a detailed history taking of headache and vasomotor symptoms, MIDAS and VAS scores. Measurement of Estradiol (E2) and FSH levels was done for all participants. Comparisons were done between group 1 and group 2 by migraine characteristics, vasomotor symptoms and Estradiol and FSH levels. Group 3 (control) was compared with both migraine groups 1 and 2 by vasomotor symptoms and Estradiol and FSH levels. Statistical analysis was performed by using SPSS 27th edition Statistical tests used include mean, median, count, Mann-Whitney U, Kruskal-Wallis test, Chi-squared test and the Spearman correlation test (The suitable test was chosen based on the type of variables and data, and the number of comparison groups).</p> Results <p>Migraine with onset during perimenopause was characterized by throbbing pain, alternating laterality, orbito-fronto-temporal site, moderate to severe intensity, high frequency, with associated phonophobia and photophobia, while autonomic symptoms were rare. There was analgesic overuse and an unsatisfactory response. Group 2 significantly had more postdrome symptoms, less analgesic response and more menstrually-triggered migraine than Group 1 (P &lt; 0.05). Both perimenopausal migraine groups (Group 1 and 2) had significantly more perimenopausal symptoms, including fatigue, sleep disturbance, mood symptoms and anxiety (P &lt; 0.05) compared to the control (Group 3). Hot flashes, night sweating and vaginal dryness were more common in migraineurs without statistical significance. Migraineurs had significantly lower Estradiol levels and a higher proportion of subjects with Estradiol &lt; 50 pg./ml than controls (P &lt; 0.05). There was a significant negative correlation between Estradiol and scores, including MIDAS (Rho=-0.406, <i>P</i> = 0.007) and VAS (Rho= -0.331, <i>P</i> = 0.030). No difference in the FSH levels among the Groups.</p> Conclusion <p>Perimenopause is associated with high-frequency, moderate to severe migraine headache. Lower Estradiol levels were correlated with high migraine severity scores (VAS and MIDAS). The frequency of perimenopausal symptoms is higher, whereas the Estradiol level is lower in migrainous compared to nonmigrainous women.</p>