Dr. frank june 13 women headaches

Women and Migraine

The Prevalence and Diagnosis of Migraine in a Primary Care Setting –The Landmark Study

Background:• To determine the prevalence and diagnosis of migraine in

patients presenting to primary care physicians (PCPs) with a complaint of headache

Study Design:• Prospective, multi-center, international study• PCPs from 128 centers in 14 countries recruited 1203 patients• Recruited patients consulting PCP with complaint of headache• PCP diagnosed patients via customary practice • Expert panel made final headache diagnoses for patients with

a new migraine diagnosis or a non-migraine diagnosis (n=377)

Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting; July 16-20, 2002; Lake Buena Vista, Fl.

Patients Presenting with Headache Most Likely Have Migraine

Of 377 patients who returned diaries:

Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting; July 16-20, 2002; Lake Buena Vista, Fl.

Episodic Tension Headache

3%

Migrainous 18%

Migraine

76%

Other 3%

Why Women and Migraine?

• Women have Migraine 3:1 compared to

men.

• In peak years (20 – 50) , Migraine affects

25% of women (1 in 4).

• Migraine will affect 40% of women by age

50.

Prevalence of MigraineAge and Gender

Peak prevalence at age 40 years Greatest impact on ages 25 to 55 years

Lipton RB, et al. Headache. 2001;41:646-657.

0

5

10

15

20

25

30

0 20 30 40 50 60 70 80 90

Age (years)

Mig

rain

e P

reva

len

ce

(%

)

Females

Males

Female Life Events That Influence Migraine

• Menarche• Menses• Oral Contraception• Pregnancy• Lactation • Menopause• Hormone Therapy

Migraine and Menarche• Females suffer from migraine at a 3:1 ratio to

males• Beginning with puberty, migraine is more

common in girls • Menstrually-associated migraine begins at

menarche in 33% of women• 60-70% of female sufferers experience migraine in

association with menses MacGregor EA. Neurologic Clinics. 1997;15(1):125-141.

Silberstein SD, Merriam GR. Neurology. 1991;41:786-793.

Benedetto C et al. Cephalalgia. 1997;17(suppl 20):32-34.

Menstrual Migraine: Definitions• Menstrually-associated migraine (MAM):

– Women who experience attacks that occur both perimenstrually and at other times of the month

– 60-70% of female migraineurs report a menstrual relationship to their headaches

– MAM is also referred to as menstrually-related migraine (MRM)

• Menstrual migraine (MM):– Women who experience attacks that occur only

perimenstrually– True menstrual migraine occurs in only 7-14% of

female migraineurs

Benedetto C et al. Cephalalgia. 1997;17(suppl 20):32-34.

Role of Estrogen

• Estrogen is a neuromodulator.• A decrease in estrogen increases the

Trigeminal mechano- receptor field which in turn increases pain perception and increases cerebral vasoreactivity to serotonin.

Role of Estrogen

• In other words, a decrease in estrogen can precipitate migraine.

Hormone Levels During Menstrual Cycle

Adapted from Hatcher RA, Trussell J, Stewart, F. Contraceptive Tecnhology, 17th Revised Ed.

New York, NY. Ardent Media, Inc. 1998:Appendix, Figure 2.

HORMONAL FLUCTUATIONS DURING THE MENSTRUAL CYCLE

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29Day of Cycle (day 0 is start of blood flow)

Hor

mon

e L

evel

s T

hrou

ghou

t Cyc

leFollicular Phase Luteal Phase

Endocrine Cycle

LH

FSH

E2

POvulation

Treatment of Menstrual Migraine

• Symptomatic

• Prophylactic

• Hormonal Manipulation

Migraine and Oral Contraceptives

Migraine and Oral Contraception

• Concerning migraine, 1/3 stay same, 1/3 improve, and 1/3 worsen.

• Triphasic preparations may make migraine worse due to fluctuating levels.

• Lowest dose of estrogen best for migraine.• Progesterone only pills do not affect

migraine.

Migraine and Oral Contraception

• Biggest risk of migraine is during hormone

free period.

• Newer preparations like Nuvaring may be

better due to constant low dose estrogen

release.

Migraine and Oral Contraception

• New or persistent Headache

• New onset of migraine with aura.

• Prolonged aura

Red Flags

Migraine and Oral Contraception

• Risk of stroke in healthy female <45 is 5-10 / 100,000.

• Odds ratio(OR) with any migraine – 3

• OR with migraine with aura – 6

• OR with migraine and OC – 5 – 17 (migraine with aura

higher end)

• OR with migraine, smoking, and OC - 34

Risk of Stroke

Migraine During Pregnancy

Impact of Pregnancy on Migraine• 60-70% improvement in the frequency of

migraines, particularly in the 2nd and 3rd trimesters

• 4-8% of women experience worsening of symptoms

• Approximately 10% of migraine cases start during pregnancy

• Pre-pregnancy headache pattern returns almost immediately postpartum

• Independent of migraine type

Aube M. Neurology. 1999;53(S1):S26-S28.

Treatment of Migraine during Pregnancy

• Treatment is challenging due to risk to

baby.

• Magnesium, B2, and CoQ10 are probably

safe.

• Otherwise need to weigh benefits vs risks.

Migraine and Lactation

Migraine and Lactation

• Generally medications safe during

pregnancy are safe during lactation.

• Notable exceptions are Benadryl and

Cyproheptadine.

• Triptans are still recommended to pump and

dump.

Migraine and Menopause

Migraine and Menopause

• Preexisting Migraine– improves - 8% - 36%– worsens - 9% - 42%– unchanged - 27% - 64%

• New Migraine may develop in 8% - 13%

Migraine and Menopause

• In perimenopause, headaches may be worse due to fluctuating hormone levels.

Migraine and Hormone Replacement Therapy

Migraine and HRT

• Migraines improved - 22%

• Migraines worsened - 21%

• Migraines unchanged - 57%– migraines likely to be unchanged if natural

menopause had no effect on them

Hodson et al /2000

Update on Migraine Chronic Daily Headache

• Typically is a bilateral, constant headache

which occurs nearly daily

• Can fluctuate in intensity and at times have

characteristics of migraine

• Are frequently “transformed migraine”

Update on Migraine Chronic Daily Headache

• Typically associated with taking analgesic

medication on a daily basis (medication overuse

headache)

– acetaminophen, Excedrin, ibuprofen, butalbital,

Midrin, narcotics, and even the 5HT 1b/1d agonists

• Prophylactic medication will not work if analgesic

rebound present

Questions?

Dr. Jeffrey Frank, M.D.Neurologist

Norton Neuroscience Institute

(502) 629-2602