Hormonal aspects of migraine

Transcription

1 Hormonal aspects of migraine

2 Migraine tends to affect three times more women than men. Menopause and during and after pregnancy can also increase the likelihood of a migraine attack. The good news is that steps can be taken to help reduce the frequency and severity of attacks. What causes migraine? It is believed that everyone has the capacity to suffer from migraine but in 10% - 15% of the population there is an increased susceptibility as the threshold at which an attack is triggered, is lowered. Migraine is thought to be caused by a release of neurotransmitters (chemical messengers) through nerve endings in the trigeminal system located in the brain. When a migraine attack has been triggered, the bloods vessels in the brain are thought to expand. However, exactly what prompts these changes is still unknown. There are certain predisposing factors that can cause individuals to deal with circumstances, such as stress, in a different way and in turn can result in a migraine. Some people have a genetic predisposition, where a parent or grandparent may have a history of migraine. For others a head injury or depressive breakdown could be a contributing factor towards their migraine. The list of internal and external triggers factors, such as certain foods, tension, hunger, travel etc. that can contribute towards an individual s migraines is numerous and peculiar to the individual. For many people it is just not one trigger but a culmination of factors which individually can be tolerated, but when several occur together can result in a migraine attack. If you would like more information and help to identify your triggers, please visit or contact us on to request a booklet.

3 Hormones and migraine The number of boys and girls experiencing migraine is similar until around the age of 12 years when, due to puberty and hormonal changes, it becomes much more common in girls and this trend continues into adulthood. In women, there seems to be a hormonal determinant or gateway which is affected by changes in the levels of the ovarian hormones, oestrogen, progesterone and other related hormones. When the level of these two hormones is high, as during the last few months of pregnancy, the hormonal gateway is closed and few attacks of migraine occur. In fact, in late pregnancy many women find that their usual triggers do not bring on a migraine attack. However, when the levels of both hormones fall as during early menstruation or after childbirth, the gateway is open and attacks occur at the slightest provocation. The gateway would seem to be partially open at times of hormonal instability as at puberty and menopause. Research has found that the changes in hormonal levels (oestrogen and progesterone) that take place when taking the pill, pregnancy, during menopause or after a hysterectomy seem to affect all women differently. (See our Migraine and pregnancy information booklet for more information about changes to your migraine during pregnancy). Whilst, a few women find an improvement to their migraine, others have found the frequency and severity of their migraine worsening and in some women who have never experienced migraine before, a migraine attack can trigger for the first time. Women in the post menopausal years or those who have had a hysterectomy can still experience monthly migraine attacks similar to the regularly menstruating women. This shows that their menstrual clock, situated in the hypothalamus in the brain, is still functioning. [1.].

4 Menstrual migraine 15% of women tend to experience their first migraine in the same year as the onset of their menstrual period and around 50% notice a link between migraine and their periods. However, for some women this may not be the case until they reach their late 30s or 40s even though they have had migraines since their teens or 20s. Women who often have other problems with their periods do not immediately associate the headaches they get with their periods as migraine. This can often go under-recognised by doctors too. [2.]. True menstrual migraine (perimenstrual headache) is experienced by only around 10% of women and tends to occur in the two days leading up to a period and three days following the start of bleeding. [3.]. Most women actually suffer from menstrually related migraine whereby they experience migraine attacks around the time of their period but also get migraine at other times of the month as well. What causes menstrual migraine? During menstruation oestrogen levels drop, which in turn tend to trigger a migraine attack. However, oestrogen it is not the only hormone that has been implicated. Women who notice migraine during the first few days of their period may be more susceptible to the hormone prostaglandin which is at its highest level in the body during a period, particularly in women who tend to experience heavy or painful periods, often associated with a headache. [4.]. Nevertheless, causes into menstrual migraine is still ongoing as the menstrual cycle is very complex, consisting of various brain chemicals (neurotransmitters) that have an impact upon hormones, such as oestrogen.

5 Diagnosing menstrual migraine Keeping a diary for at least three menstrual cycles will help you to effectively identify the relationship between migraine and your periods. The more information you collate the easier it will be for your GP to make a diagnosis. With there being no test for migraine, diagnosis by a healthcare professional is based upon your medical history; by looking at the symptoms and patterns of your attacks they can rule out other causes for the attacks. It is important to make a note of when your attacks occur, how frequently they take place, how long they last for, any symptoms you have, such as being sick, or having visual disturbances, and anything else that could have had an impact, such as whether you undertook any exercise, had any medication, lack of sleep etc. For more information please visit or contact us on to request a migraine diary. Self help measures Menstrual migraines can be managed the same way as non menstrual migraine. Keeping a diary will help you to identify when your period is due and to identify your non hormonal triggers. Avoiding these before your period is due can help prevent what looks like a hormonally related attack. For example, modifications to your diet and / or lifestyle could help, such as cutting out alcohol and making sure you don t get too tired, if these are your triggers. Don t wait for the pain to start. By recognising a warning sign that tells you a migraine may be starting (i.e. unusual hunger, excitability, thirst, increase in energy, strong sense of smell), you can stop what you are doing, drink a couple of glasses of water, stretch and take some deep breaths. Relaxation techniques, such as yoga or meditation can also help you to destress and relax your muscles. The list of things that migraineurs can do to help themselves once an attack has started is endless. Most people take their usual tablets and then rest somewhere away from noise and bright light. Remember that, however busy you are, a short rest in the dark early on in an attack might reduce your recovery time after an attack. Even if treatment is not started early enough to prevent an attack developing, a short rest might still reduce the severity of an attack and enable you to carry on with your day s activities. Applying soothing balms, a cold cloth, or heat packs to the head and neck have also been known to help ease the pain. Some people find that activities, such as a brisk walk, can abort an attack in the early stages; fresh air can also help.

6 Premenstrual headaches Many women are affected by premenstrual syndrome (PMS) with headaches or migraine being experienced as part of it. Premenstrual headaches tend to occur days before the onset of the next menstrual period and are associated with various symptoms of PMS, such as mood swings, irritability, fatigue, breast tenderness, bloating, abdominal pain, backaches and lack of coordination. Some women may also experience an increase in appetite and a craving for chocolate or other sweet things. Most of these symptoms tend to improve as the menstrual flow starts and are best treated with standard treatments for PMS. Unfortunately, only a few highly effective treatments are available (listed below) and therefore it may be better to manage PMS through identifying your trigger factors and making changes to your lifestyle, such as keeping hydrated, maintaining regular sleep patterns, getting fresh air, daily exercise and practising relaxation techniques, which are known to help. Treatments for PMS: Vitamin B6 also known as pyridoxine is normally recommended for mood swings and irritability. Speak to your GP or pharmacist before taking a high dose due to possible side effects. Magnesium supplements 200mg three times a day helps with abdominal bloating and breast tenderness. Primrose oil - taking a dose of 1.5mg twice daily can help with premenstrual breast tenderness. Non hormonal treatments bromocriptine (e.g. Parlodel) and cabergoline (Dostinex) can help to reduce the output from the brain of a hormone called prolactin, which stimulates the production of milk. Fluoxetine (an antidepressant) can help with moods swings and irritability. Hormonal treatments oral or injectable contraceptive pills can work by switching off the normal menstrual cycle, inhibiting ovulation. Speak to your GP before taking any of the above treatments to ensure they are right for you.

7 Treatment of menstrual migraine Various studies conducted on hormonal levels have been unable to identify any differences between women with migraine triggered by hormonal changes and women without migraine. Therefore, to some extent treatment can be a matter of trial and error, and its effectiveness is usually dependent on various factors, such as the stage of the menstrual cycle at which an attacks occurs, the regularity of the menstrual cycle, whether or not you have heavy or painful periods, menopausal symptoms and if contraception is required. Currently, there are no drugs that are specifically licensed for menstrual migraine; however, doctors can prescribe them for this condition if they feel that it would be of benefit. Some of the medications that may be suggested by your GP are listed below: Acute treatment If migraine attacks are occurring once or twice a month, taking effective acute treatment when an attack strikes may be sufficient in helping to abort it. The treatment options are the same as for any other migraine attack and include the following: Painkillers Many people treat their migraine with simple painkillers bought over the counter, such as aspirin, ibuprofen, paracetamol or codeine. If these do not give significant relief, your doctor can prescribe stronger painkillers (e.g. diclofenac, naproxen) or painkillers combined with anti-sickness ingredients, such as metoclopramide and aspirin. Taking a combination of painkillers, such as acetaminophen, aspirin, and caffeine have found to be effective in treating menstrual migraine. For more information on painkillers, please visit or contact us on to request a booklet. Ergots Menstrual migraines can be aborted by taking medication containing ergotamine, such as Dihydroergotamine (DHE), which is not a painkiller but prevents the pain of a migraine attack by acting on the blood vessels. Ergotamine (oral, rectal or intranasal) and DHE (intranasal, intramuscular or intravenous) can be used to prevent menstrual migraine by taking it several days before your menstruation and continuing to use it for the duration of the expected headache.

8 Triptans Triptans or 5HT agonists have been specially developed to treat migraine; they act directly to correct the serotonin imbalance which is believed to cause a migraine attack. There are currently seven triptans available which include sumatriptan (Imigran), rizatriptan (Maxalt), naratriptan (Naramig), zolmitriptan (Zomig), eletriptan (Relpax), and frovatriptan (Migard). Whilst many of the triptans have been found to be effective in aborting menstrual migraine, frovatriptan has been recommended as the preferred therapy as it tends to stay in the body for longer (up to 26 hours), with individuals only having to take one tablet a day, reducing the risk of medication overuse. Although, not currently licensed for migraine prevention, triptans have also proven to be effective in reducing the frequency and severity of menstrual migraines. Taking frovatriptan (2.5mg twice on the first day and then 2.5mg daily), naratriptan (1mg twice a day) or sumatriptan (25mg twice a day) can help to prevent menstrual migraine. Most triptans are available on prescription only and are not suitable for all patients. Taking triptans together with ergotamines, anti-depressants, lithium, methysergide or other 5HT agonists is not recommended. Therefore, you should speak to your GP or pharmacist about any other medications you may be taking. Acute migraine treatments are available in a variety of forms including tablets, soluble tablets, capsules, suppositories, injections and nasal sprays. It is important to take medication at the first sign of an attack, before gastric stasis (a shut down of the digestive system) occurs, which prevents the absorption of medication into the blood stream. Painkillers taken in a soluble form or tablets taken with a fizzy drink can start to work more quickly. Most of us prefer not to take drugs if possible but with an attack of migraine speed in taking action can make the difference between a normal day and one spent in pain and misery.

9 Preventative treatment For some women treating each attack may not work, particularly if you suffer from severe menstrual migraine attacks. In this instance your GP may prescribe you preventative (prophylactic) treatment which will help to reduce the frequency and severity of your attacks. These sometimes take a while to show full benefit so you will probably need to try them for at least three to six months. The following preventative treatments might be recommended by your GP: Non steroidal anti-inflammatory drugs (NSAIDS) Mefenamic acid inhibits the release of protaglandin and can be effective in preventing migraine, particularly if you suffer from heavy and / or painful periods. A suggested dose of around 500mg 3-4 times a day can be started on the day of your period or 2-3 days before. This medication can be taken if your periods are irregular or if you are trying to get pregnant. Naproxen has found to be effective on doses of 500mg taken once or twice [5., 6.] daily around the time of menstruation. Oestrogen supplements Supplementing oestrogen just before and during a period can help to prevent the drop in oestrogen levels that occur, triggering a migraine. These are only normally prescribed if you do not require contraception and if your periods are regular and predictable: Oestrogen skin patches a dose of 100 micrograms can be used from around 5 days before you expect your period to start, up to the 5th day of menstruation. The oestrogen travels through the skin into the bloodstream. For the last few days of the treatment the dose should be lessened by cutting the patch in half. It can be effective for some but if side effects, such as bloating, breast tenderness, leg cramps etc. pose a problem, speak to your GP about reducing the dose to 50 micrograms for your next cycle. Oestrogen gel 1.5mg of estradiol gel can be applied daily from around 5 days before your expected menstruation date until the 5 th day of menstruation, lessening the dose of oestrogen for the last few days. Some women who take oestrogen supplements may experience delayed attacks when the supplements are stopped. In this instance your GP may recommend extending the supplements until the 7 th day of the cycle when your oestrogen levels start to rise naturally.

10 Hormonal or contraceptive strategies These are recommended for women who require contraception or if their periods are irregular: Combined oral contraceptive pill or patch helps to switch off the natural menstrual cycle and maintain oestrogen levels for 21 days. Migraine can occur during the seven day hormone-free interval therefore, your GP may recommend taking the pill continuously for three or four packets (nine to 12 weeks) without any breaks, followed by a seven day pill-free interval. This treatment is not suitable for women who suffer from migraine with aura due to the increased risk of ischaemic stroke. Instead progestogenonly methods are recommended. [7.]. Progestogen-only pill (mini-pill) e.g. Cerazette works like the combined contraceptive pill but does not contain oestrogen. Many women do not get a period as the pill is taken daily, without any breaks. Occasionally, however irregular bleeding can occur. This pill can be taken by most women with migraine at any age, but would need to be stopped if migraine attacks with aura develop after having taken the pill. Injectable depot progestogens these tend to be given every 12 weeks and work similar to the combined contraceptives. Most women find after having taken this for a few months their periods stop completely. Therefore, initially you may still experience migraine with bleeding. The Mirena intra-uterine system is a contraceptive device that is inserted into the womb where it releases small amounts of progestogen locally, preventing the lining of the womb thickening in response to oestrogen. As well as acting as a contraceptive, it produces lighter and less painful periods and has helped to improve migraine for some women. However, it does not seem to be effective for women who are sensitive to oestrogen withdrawal as a migraine trigger because their normal hormone cycle continues. If attacks continue after having tried a particular preventative treatment do not give up hope, try a different treatment and speak to your GP about other options. Migraine is an individual condition with individual triggers requiring individual treatment and hormonal triggers are no different. It is important to remember that hormones are not the only reason why migraine is more common in women; most women have a very hectic lifestyle taking no time out for themselves. Try and put yourself first at least once every day.

11 Menopause The menopause, in strict medical terms, is the last menstrual period. However, the term the menopause is often used to cover all the hormone fluctuations and symptoms that women get, both before and after, the last menstrual period. These are usually caused by the failure of the ovaries to produce more oestrogen and progesterone. The more common symptoms that occur in relation to the changing hormone levels include hot flushes, night sweats, panic attacks and mood swings. There are also subtle hormone changes that can occur over time causing vaginal dryness, painful intercourse reduced libido, thinning hair and skin and skin irritation. During long term oestrogen-deficiency, diseases such as osteoporosis, thinning of the bones - brittle bones, heart disease and strokes can be of concern, particularly, as there is no natural oestrogen being produced which would normally act as lubricant - helping to lubricate the joints and increase blood-flow. Perimenopause The years leading up to the menopause and shortly after are called the perimenopause. Perimenopause can begin for some women in their mid-30s and can last for as long as 15 years. With the average age for menopause being around 52 years, most women will start to notice some symptoms when they are in their 40s. [8.]. It s during this time that many women find their migraine gets worse and those who hadn t noticed much of an association with their periods before start to develop regular monthly migraine attacks. Migraine attacks can become more severe and frequent due to fluctuating and changing hormonal levels. This in turn can affect your monthly cycle and cause you to experience various symptoms, such as night sweats and insomnia which can impact upon your sleep and increase your susceptibility to migraine. However, this is not the case for all, for women whose headaches are triggered by their menstrual cycle; the lack of periods after menopause can actually help to improve their headaches. Some women find that as they get older their headaches become less severe and they experience a reduction in the pain and frequency of their headaches during and after menopause. About 67% of women find that their migraines go away or improve significantly after menopause [8.].

12 Treatment for menopausal headache The usual preventative and acute treatments, such as triptans, can be used to help treat migraine for those women who continue to get them. Women 65 years or older should consult their doctor regarding whether triptans are safe for them to use, due to the theoretical risks of causing a heart attack or stroke. Another option for women undergoing menopause is hormone replacement therapy (HRT): Hormone replacement therapy Some people, including some doctors, believe that HRT will make migraine worse. However, HRT can actually help perimenopausal migraine as well as improve other menopausal symptoms and protect you against osteoporosis. It's not a treatment that should be given solely for migraine, but if it s needed for other reasons, the route and doses of HRT can be optimised to actually make migraine better. What does HRT do? HRT replaces oestrogen that is normally produced by the ovaries and is normally recommended to be given to women whose ovaries aren t producing anymore oestrogen or their egg production is waning. It differs from the combined contraceptive pill in that it uses low doses of natural oestrogen; although, some of them are made synthetically, they are structurally in most cases exactly the same as the oestrogen that is made by a woman s own ovaries. The combined contraceptive pill on the other hand uses high doses of synthetic oestrogens to stop the ovaries releasing an egg every month. HRT is not a contraceptive; unless you have had your womb removed, are in your mid- 40s and require HRT, you will need to take contraception along with progestogen. This helps to protect the lining of the womb from too much oestrogen and reduces the risk of developing cancer of the uterus.

13 Types of HRT There are many different types of HRT available and the choice of how HRT is given really depends on how old you are and at which stage of the menopause you are at. If you are just coming up to the menopause with slightly irregular periods, hot flushes and night sweats, your doctor may give you oestrogen to take every day along with a monthly course of progestogen that will last about two weeks. On finishing the course of progestogen you are likely to have a withdrawal bleed that is like a period. If you are postmenopausal, whereby your periods have stopped for a year or more, you are likely to be advised to take oestrogen and progestogen together every day without having a monthly period. Women who have very erratic or sparse periods but still have some hormonal activity may benefit from having a course of progestogen every three months for a short period of time. How to take HRT There are many different ways that you can take oestrogen. Many people start off on tablets but there are patches or gels that you can rub on to the skin. Women who have had hysterectomies can have an implant inserted underneath the skin every six months and there are also local oestrogens (placed directly into the vagina) that can be given as well. How HRT is administered is important for migraineurs as it can impact upon their migraines. Research suggests that women with migraine do better with non-oral routes of HRT, such as patches or gels. Oral routes of HRT tend to cause oestrogen levels to fluctuate dramatically; when a tablet of oestrogen is taken, oestrogen levels can go up sharply immediately after it and then drop sharply before the next tablet is taken, causing dramatic peaks and troughs in levels. With patches and gels there is a much more stable rise in hormone levels and as they are replaced the levels continue to stabilise. Dosage Getting the dose of HRT correct is extremely important. Too little HRT, particularly in the years leading up to the menopause can result in fluctuations of a woman s own hormones breaking through and those falling levels can still trigger migraine attacks. However, too much oestrogen can result in fluid retention, breast tenderness, nausea, leg cramps, stomach discomfort and headaches; interestingly, it can also trigger migraine with aura. This may be due to an extra susceptibility to a particular threshold of oestrogen. These symptoms can be avoided by either reducing the dose of oestrogen or changing the delivery route, particularly from tablets to a patch form of HRT.

14 Progestogen Progestogen, a substitute for the hormone progesterone, can also be administered by different routes although not quite as many as with oestrogen. Typically, they come in tablet form or in patches but they have to come combined with oestrogen. You can use a contraceptive device - the Mirena intra-uterine system which releases a small amount of progestogen hormone onto the womb lining, making it thinner, and hence making heavy periods lighter. However, it is not licensed for HRT in this country at present. There are some other natural progesterone gels that you can use and there are progesterone suppositories for those people who can t tolerate the synthetic progestogen. Unfortunately, synthetic progestogen is usually used for HRT, unlike natural oestrogen, because most people using progesterone find it has a sedating effect. Side effects of progestogen The side effects of progestogen can be a problem for many women with headache or migraine. After having taken a cycle of progestogen, some women experience an exacerbation of their headache and in some cases, migraine. Other side effects include fluid retention, poor mood, a cramping feeling that you sometimes get just before a period and irritability - typical pre-menstrual type symptoms. However, everyone is different; to see how it impacts you, it is important to keep a diary. If migraine attacks always occur during the progestogen course of HRT, it can be remedied by changing the type of progestogen. If you are taking tablets of progestogen you can change these to perhaps a combined patch or try the natural progesterone in a suppository form. The problem often goes away when women are able to change from taking progestogen cyclically, to taking it continuously. It is important that you do not stop the progestogen suddenly, particularly if you are taking oestrogen and you have a womb as there is a very small possibility of developing cancer of the lining of the womb.

15 Other treatments Not everybody can take HRT and not everyone needs it. If you are one of those people who doesn t want to take HRT but you have got hormonal problems and are looking for alternatives, you might want to try a prescription drug called Clonidine, which has been licensed for the treatment of migraine and menopausal hot flushes. Some people find it very effective, others do not. It is one of those things you may wish to try to see if it works for you. Clonidine should not be taken if you have a history of depression as this can be made worse. Non drug treatments Lifestyle changes Exercising regularly and having a healthy well balanced diet can help you to cope better with the symptoms of menopause and migraine, and it can protect you from other diseases, such as heart disease and osteoporosis. Phytoestrogens Phytoestrogens also known as isofalvones, are plant compounds similar to oestrogen which can help with hot flushes and sweats. They can be ingested through food sources which include soy or herbs, such as black cohosh. Supplements containing isofalvones can be purchased in a tablet or shake form. Studies using isoflavone supplements recommend taking 40mg - 80mg a day; however, full benefits may not be seen until after a few weeks. Herbal medication Some people find that natural progesterone can be effective and there is increasing evidence for herbal preparations, such as St. John s Wort and Red Ginseng, which help to reduce blood pressure. Lots of other herbal formulation are used but these are the only ones for which there is some evidence, although not much is available due to a lack of controlled trials. Homeopathic remedies have also been found to be popular; sepia, sulphur, nat mur and calcarea are the four that are reported to be the most effective. It is important to remember that even herbal medicines can have side effects that may interact with other medication (herbal or conventional). Therefore, when speaking to your GP or herbalist you should be clear about other medication you are taking so that they can advise you of any problems.

16 Would having a hysterectomy help? Hysterectomy as a treatment for menstrual or menopausal migraine rarely seems to be effective, with many women finding their migraines often worsening after a hysterectomy particularly if the ovaries are removed. However, if a hysterectomy is required for other medical reasons the effects of migraine are probably less, as women are usually given oestrogen replacement therapy. During menopause it is better for you to try and keep your hormone levels as steady as possible. With migraine being an individual condition there is no way to predict what will happen; however, there is a good chance that attacks will improve as oestrogen levels stabilise after menopause. Relieving migraine headaches during menopause involves finding what works best for you. It may require a lot of trial and error to identify triggers and find a suitable treatment plan. Speaking to your GP will help you to find the best course of action to help you to better manage your migraine and menopause.

17 Case studies Pennie Woodhead, one of our members from Bedfordshire describes her experience of migraine which started at the age of 42 years, when she became peri-menopausal. Pennie says: l wasn t a migraineur when I was younger and there is no history of migraine in my family but I started to get attacks at the same time as I got other menopausal symptoms. lnitially the attacks came with my period, then ovulation time added itself in, and then as my periods became even more erratic, it seemed that l would get a migraine at every hormonal opportunity. The gaps between attacks just seemed to get less and less. Since my periods have ended at the age of 54 years, I have continued to get around one migraine a week. I tend to get a dreadful pain in my head and neck, feel nauseous and suffer an upset stomach during some attacks. My migraines can be exacerbated by smells and lighting but I think the main trigger must be hormonal. I have tried various different preventative medications to see if they help as my migraines are having a big impact on my life but sadly none have. I can only hope my hormones might eventually settle and take the migraines with them. Sue Oxley, aged 59 years from Somerset began to get migraines after she started her periods at the age of 14 years. She experienced up to three a week and found that her triggers included heavy atmospheric pressure, bright sunlight, chocolate and cheese. During her attacks she experienced a one-sided headache, nausea and also aura symptoms, such as flashing lights and pins and needles in her hands and on her face. Her attacks worsened at the beginning of each of her three pregnancies, which then eased off and returned to their more usual pattern after giving birth. Having reached menopause at the age of 45 years, Sue has found that her migraines are much better. She says: l ve had a difficult menopause lasting 15 years. When I became perimenopausal I began taking HRT but my migraines seemed to get worse so I stopped taking this. Attacks decreased in number and intensity as things settled down and I now feel like my migraine threshold has increased. As long as I don t go mad I can enjoy chocolate and cheese again without an attack being triggered. I now only get one attack a month and this is usually triggered by flashing lights or sunshine; I find that they can usually be easily controlled with medication from the pharmacy.

18 FAQs I get migraine attacks around the time of my period and at other times too. My doctor says it is not menstrual migraine, but how can this be? If you have menstrual migraine you only get migraine attacks two days before the first day of your period and two days after the first day of your period, not at any other time. It sounds like you actually get menstrually related migraine, whereby you get attacks at the time of your monthly period as well as at other times too. I seem to be getting migraines around the time of my period, do you know why this is and what I can do to stop them happening? Migraine can occur at other times to; however, many women seem to be more susceptible to getting migraine around the time of their period due to various internal and external trigger factors, such as falling oestrogen levels, dehydration, fluctuating blood sugar levels, stress, tiredness etc. which lower their threshold levels. Normally these factors would be individually tolerated, but when several occur together it can result in a migraine attack. The best thing to do is to keep a diary, noting down things like when your attacks occurred, how long they lasted for, any symptoms you had, the date your period started and ended, any medication you took and things that could have impacted upon your migraine. It is a good idea to keep a diary for three to six months as you may not get a migraine with every period. Having identified what contributes toward your migraine, you can take preventative action to stop them from happening. If a drop in sugar levels is your trigger, you can make adjustments to your diet which could involve keeping your blood sugar levels stable, eating regularly and making sure you are well hydrated. Medication taken early enough can help to abort an attack and stop gastric stasis (a shut down of the digestive system), which prevents the absorption of medication into the blood stream.

19 I have menstrual migraine and have been recommended by my GP to try hormone treatment, can this help? During menstruation it is the rise and fall of oestrogen levels that can cause a migraine attack. Hormone treatment can help to ease the fluctuations that occur. It is important to take the treatment at the right time, this could mean starting the oestrogen two days before you expect the attack to happen and continue to use if for seven days. Taking oestrogen in a gel or patch form has found to be more effective as it delivers a constant level of the hormone into the bloodstream. In order to use this approach your periods need to be regular. People say my migraines will get better when I stop getting my periods, is this true? Many women do find that their migraines go away or improve after menopause, once their periods have stopped. However, this is not the case for all, sometimes they can get worse or stay the same. With migraine being an individual condition it is hard to tell. Since my periods have become more irregular, my migraines have seemed to worsen. It has been mentioned to me to consider HRT, having read up about it, I am not sure what to do? Hormone replacement therapy (HRT) helps to regulate oestrogen levels and keep them as steady as possible. It is the rise and fall in oestrogen levels that has been implicated in lowering your migraine threshold, so that when other trigger factors are present, a migraine is more likely to occur. Some research undertaken on HRT has shown an increased risk of getting breast cancer, stroke and heart disease increases in women who have had HRT for many years. In considering HRT as a treatment you need to think about your personal risk of developing any of these conditions. For example, if you have a family history of breast cancer, your risk of getting it is higher than someone who has no family history of breast cancer. You need to speak to your GP and decide whether it is right for you, taking on board factors, such as your age, health and medical history which could have an impact.

20 Web: Acknowledgements Migraine Action would like to thank Dr Andy Dowson, Director of Headache Services, King s College, London, Dr Manuela Fontebasso, GP with a specialist interest in headache and migraine, York Headache Clinic and Dr Anne MacGregor, Director of Clinical Research, City of London Migraine Clinic for reviewing and providing information used in this booklet. References 1. Dalton K., Hormonal Aspects of Migraine in Women, Migraine Action Newsletter. 2. Lipton R., Stewart W., Celentano D., Reed M., Undiagnosed migraine headaches: a comparisons of symptom-based and reported physician diagnosis. Arch Intern Med. 1992: 152: MacGregor EA., Hackshaw A., A prevalence of migraine on each day of the natural menstrual cycle. Neurology. 2004; 63(2): Chan W., Prostaglandins and nonsteroidal anti-inflammatory drugs in dysmenorrhoea. Ann Rev Pharmacol Toxicol. 1983; 23: Szekely B., Meeryman S., Post G., Prophylactic effects of naproxen sodium on perimenstrual migraine: a double-blind placebo-controlled study. Cephalalgia. 1989; 9: Nattoro G., Allias G., De Lorenzo C., et al. Biological and clinical effects of naproxen sodium in patients with menstrual migraine. Cephalalgia. 1991;11: World Health Organization. Improving access to quality care in family planning. Medical eligibility criteria for initiating and continuing use of contraceptive methods. Third Ed. Geneva:WHO, Bernstein C., The Migraine Brain. Souvenir Press. 2010; Bibliography Web resource: Web resource: Web resource: Web resource: Web resource: 4 th Floor, 27 East Street, Leicester. LE1 6NB. Tel: Fax: info@migraine.org.uk Web: Registered Charity No Copyright 2009 Migraine Action This publication provides information only. Migraine Action and its officers can accept no responsibility for any loss, howsoever caused, to any person acting or refraining from action as a result of any material in this publication or information given. Whilst this booklet has been reviewed for accuracy by members of Migraine Action s Medical Advisory Board and other experts, the information does not necessarily reflect the views of individuals. Medical advice should be obtained on any specific matter.