April 20, 2013Hormonal Headaches
Migraines headaches are an episodic, often debilitating condition most frequently suffered by women. Unlike other chronic pain conditions, migraines are most prevalent during years of peak productivity, when many women are juggling family responsibilities and their careers. Three times as many women suffer with migraines than men; statistics show that 43 percent of American women will suffer from a migraine headache during their lifetime. About 4% of American children experience migraine headaches, with boys and girls affected equally. During puberty, however, girls begin experiencing migraines much more frequently than do boys, largely due to hormonal fluctuations. The good news is that headaches usually improve or disappear after menopause; the bad news is that they often worsen during the peri-menopausal years, requiring treatment for improved quality-of-life.
Menstrually-associated migraines (MAM) are those headaches that occur regularly around the time of a woman’s monthly period, and possibly at other times of the month, too. There are no tests to diagnose a migraine, but a history of headaches severe enough to reduce full functioning -- possibly associated with one-sided throbbing pain with nausea, and sensitivity to light and/or sound – is usually sufficient to make the diagnosis. About 60 percent of women who experience migraine headaches have MAM – meaning more frequent migraines around the time of their menstrual period.
Researchers believe that fluctuating estrogen levels, particularly precipitous drops of estrogen just before menstruation, trigger MAM. Interestingly, other medical conditions such as epilepsy, asthma, rheumatoid arthritis and irritable bowel may also worsen during menstruation. Headaches generally improve with stable, high estrogen levels found during the second and third trimesters of pregnancy, and stable low levels found during menopause. However, abrupt drops of estrogen, such as after hysterectomy, may worsen migraines.
The use of medications containing estrogen, such as oral contraceptive pills (OCs) or hormone replacement therapy (HRT), have a varying effect on migraines. In a study of 500 women migraine patients that I published, about 70% of women on OCs noted no change in their headaches, while 15% worsened and 15% improved. There was no way to predict who would worsen based on prior hormonal influences on headaches. In addition to concerns about worsening of headaches, there are concerns about an increased risk of stroke for women with migraines who take OCs, prompting the following national recommendations: women who experience migraines without neurological symptoms, called “aura,”(migraine without aura) should not use estrogen OCs if they are older than 35, nor should women of any age who experiences migraines with “aura.” These national guidelines are somewhat controversial, as recommendations are based on older studies that used higher-dose estrogen pills. Ultimately, treatment options are best made between a patient and their healthcare provider, after discussing treatment options and being fully informed about the risks and benefits of therapy.
Most standard treatment approaches work as well for MAM as for non-hormonal headaches.
First-line symptomatic treatment with “migraine-specific agents” such as triptans (Axert, Amerge, Imitrex, Maxalt, Zomig) may be indicated if headaches limit function. These medications are usually more effective than simple pain killers in alleviating pain and associated symptoms, such as nausea, without causing tiredness. For frequent or hard-to-treat headaches, daily preventative medications -- such as beta blockers, calcium channel blockers, anti-inflammatories, antidepressants, or anticonvulsants – may be considered.
“Peri-menstrual prevention” is a unique treatment opportunity for women with predictable menses and predictable MAMs that are particularly severe, prolonged, and/or resistant to standard therapies. For example, an anti-inflammatory drug, such as naproxen sodium (Anaprox, Aleve) can be started two days before expected MAM and continued daily during the usual time span when headaches typically occur.
Hormonal manipulation is usually reserved for patients with MAM who have failed standard treatments. Stabilizing estrogen levels, at least in theory, should improve migraine, especially for patients with hormonal triggers. This can be accomplished in several ways. Continuous OCs may be considered, using a three-month brand of OC, or combining monthly OC pill packs consecutively without using the placebo weeks. If everything works as planned, menstruation occurs only three to four times a year, with reduced MAM frequency. Unfortunately, unpredictable breakthrough bleeding with worsening headaches may occur in some migraine patients.
Understanding these various treatment options and their associated risks and benefits is the first step to a therapeutic relationship between patient and provider. I encourage all those who suffer from migraines to keep a detailed headache calendar (available on www.MyHeadacheDoctor.com) and to schedule an appointment with a provider knowledgeable in headaches to formulate an individualized therapeutic plan for this very treatable condition.