Women and Migraine
Nov 20, 2014
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