dr. frank june 13 women headaches
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Women and Migraine
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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.
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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%
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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.
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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
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Female Life Events That Influence Migraine
• Menarche• Menses• Oral Contraception• Pregnancy• Lactation • Menopause• Hormone Therapy
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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.
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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.
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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.
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Role of Estrogen
• In other words, a decrease in estrogen can precipitate migraine.
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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
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Treatment of Menstrual Migraine
• Symptomatic
• Prophylactic
• Hormonal Manipulation
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Migraine and Oral Contraceptives
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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.
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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.
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Migraine and Oral Contraception
• New or persistent Headache
• New onset of migraine with aura.
• Prolonged aura
Red Flags
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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
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Migraine During Pregnancy
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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.
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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.
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Migraine and Lactation
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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.
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Migraine and Menopause
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Migraine and Menopause
• Preexisting Migraine– improves - 8% - 36%– worsens - 9% - 42%– unchanged - 27% - 64%
• New Migraine may develop in 8% - 13%
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Migraine and Menopause
• In perimenopause, headaches may be worse due to fluctuating hormone levels.
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Migraine and Hormone Replacement Therapy
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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
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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”
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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
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Questions?
Dr. Jeffrey Frank, M.D.Neurologist
Norton Neuroscience Institute
(502) 629-2602