Women and Migraine. Migraine in Women. Migraine Prevalence by Age and Gender: Adulthood Menopause

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1 Women and in Women Hormonal Influences You Need to Consider Understand the relationship between hormone changes and headache through the life span Identify changing symptoms in headache warranting re-evaluation of hormone therapy Discuss treatment of hormonally related headache Prevalence by Age and Gender: Childhood Adolescence Prevalence by Age and Gender: Adulthood Menopause prevalence, % prevalence, % Adulthood/Childbearing Yrs Menopause Perimenopause All rights reserved. ML: A Case Study prevalence, % 14-year-old female with episodic headache Headaches began with menarche at age 12½ Complaints of stomachache and motion sickness since age 8 She describes a squeezing pressure on both sides of her head, lasting about 3 hours When asked, she admits to frequently missing after-school play rehearsals Her mother offers that ML feels better after drinking cola and/or napping in a dark room Could this patient have migraine or is she too young? 1

2 in Children and Adolescents is common Prevalence is 4% to 5% for all children 7 10 years old Peak age of onset is earlier in boys than in girls (5 years old vs 12 years old) 1 is often unrecognized 2 Children assume headaches are part of life Children may fail to communicate migraine symptoms Impact of pain can be disabling 3 Missed school days; decreased social interaction Pattern of migraine shifts at menarche Fluctuating hormones may be trigger for vulnerability to migraine 2 Estrogen plays important role in modulating migraine 4 in Children and Adolescents Treatment Stable sleep/wake pattern Low vasoactive substance diet Biofeedback training 1. Dalsgaard-Nielsen T. Headache. 1970;10: Marcus DA et al. in Women. BC Decker Inc; Stang PE, et al. Headache. 1993;33: Aurora SK. in Women. BC Decker Inc; Her Headache Pattern Changes ML: Evaluation prevalence, % ML returns at age 20 with more frequent headaches s had occurred usually only on Day 1 of cycle Now migraines occur about 3 times per month, not always related to menstrual cycle Pain is moderate to moderately severe Pain is steady and throbbing; begins at base of her head and spreads up left side to her eye Photo- and phonophobia are present, as is nausea Past medical history headaches since menarche Childhood history of recurrent abdominal pain, motion sickness Family history Her mother suffered from headaches all of her life Physical exam normal Weight 118 lb, height 5 3, BP: 110/65 Overall exam unremarkable Patient is concerned about missing too many days of class at her university Evaluating the Woman With Are there other clinical questions in evaluating this patient? History is of principal importance Family history look for genetic predisposition Attack history ask about onset, type, and location of pain; aggravating factors History of related symptoms childhood car sickness; episodic abdominal pain Medical history comorbid conditions Physical examination vital signs, headache exam Diagnostic testing if concerned about another cause (ie, red flag ) for headache Nakamoto BK et al. in Women. BC Decker Inc;

3 Red Flags Pattern of Around Menses A Clinical Classification Unusually severe headache of sudden onset Unexplainable worsening of previously existing headaches Change in character of typical prodrome of headache Headache awakening patient at night Headache worsens when recumbent, coughing, sneezing New-onset headaches at older age (>50 years) without family history or in patients with cancer or HIV Headache associated with systemic illness (eg, fever, chills, rash, stiff neck) Any abnormal neurologic findings including presence of papilledema Focal deficits do not disappear after headache is over Cycle Days Premenstrual migraine (Days -7 to -2) Menstrual migraine (Days -2 to +3 exclusively) Menstrually-related migraine peaks near menses, yet is present throughout the cycle (Day menses begins) Weeks 2-3 Nakamoto BK et al. In: Loder E, Marcus DA, eds. in Women. BC Decker Inc; 2004: Loder EL et al. in Women. BC Decker Inc; Classification of Relationship of Attacks to the Menstrual Cycle Pure Menstrual 10% Unrelated to Menses 40% Loder EL et al. in Women. BC Decker Inc; 2004: Menstrually-Related 50% Pathophysiology: Proposed Mechanisms initiation Pain generation/ perpetuation Genetic predisposition Aura Cortical neuronal hyperexcitability CSD Activation and peripheral sensitization of TGVS Neurogenic inflammation TVS = trigeminovascular system. Adapted with permission from Pietrobon D. Neuroscientist. 2005;11: ? Central sensitization Abnormal brainstem function + + HEADACHE Acute Treatment Acute Treatment specific medications: triptans, ergotamines Antiemetic Rescue medications Cyclic treatment for menstrual migraine 3

4 At Age 31, ML Becomes Pregnant prevalence, % When ML started planning to get pregnant, she discussed her migraine treatment plan with her provider Now, she is 8 months pregnant Her headaches improved late in the first trimester Her migraines have remained infrequent during her pregnancy Is this patient s experience typical of migraine during pregnancy? Most Headaches Spontaneously Improve During Pregnancy and Pregnancy Patients Reporting a 50% Reduction in Headache, % 50% to 85% of migraine patients report an improvement in headaches during early pregnancy, particularly when 1 is not accompanied by aura began at menarche is related to menses Women with ongoing headache at the end of the first trimester are unlikely to experience further reduction of headache 2 headaches generally recur soon after delivery 1 Adapted with permission from Sances G et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia. 2003;23: Published by Blackwell Publishing Ltd. 1. Brandes JL et al. in Women. BC Decker Inc; Marcus DA et al. Headache. 1999;39: ML Approaches Menopause prevalence, % By age 50, ML reports irregular periods and an increase in migraine episodes By age 53, periods cease and headache frequency decreases Conjugated estrogens are tried to reduce hot flashes, but headaches increase and ERT is discontinued What can you tell your patients to expect regarding the pattern of their migraine headaches around menopause? 4

5 and Menopause can improve or worsen near menopause 1 Symptoms generally increase during perimenopause One study showed a 29% prevalence at a specialty clinic (nearly 60% reported some type of headache) 2 Clinical pattern depends on type of menopause 3 67% improve with physiologic menopause 67% worsen with surgical menopause ERT/HRT have unpredictable effects on migraine headache depending on dose and regimen used 1 Treatments Preventive Treatment 1. Silberstein SD et al. in Women. BC Decker Inc; MacGregor EA et al. Climacteric. 1999;2: Neri I et al. Maturitas. 1993;17: Consider Preventive Medication For: Preventive Medication Groups Recurring migraine that is disabling to the patient despite acute treatment Frequent attacks (>2/week) thereby increasing the risk of acute medication overuse Problems with acute medications (ineffective, contraindicated, troublesome AEs, or overused) Patient preference Presence of uncommon migraine conditions Hemiplegic Anticonvulsants Valproate Gabapentin Topiramate Antidepressants TCAs SSRIs MAOIs ß-adrenergic blockers Calcium channel antagonists Verapamil Serotonin antagonists Methysergide Others NSAIDs Riboflavin Magnesium Summary: During the Female Lifecycle Women and Menarche and Menstruation Pregnancy Perimenopause Estrogen Levels Cyclic Consistently High Irregular Fluctuations Prevalence Understand the relationship between hormone changes and headache through the life span Identify changing symptoms in headache warranting re-evaluation of hormone therapy Discuss treatment of hormonally related headache Menopause Consistently Low Lucas S. in Women. BC Decker Inc;