Headache and Migrane in Women

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Headache and Migrane in Women

• Prof. Dr. A.V. SRINIVASANM.D., D.M., Ph.D
  (Neuro), F.A.A.N., F.I.A.N,Professor in
  NeurologyInstitute of Neurology, MMC GGH
• Samyuktha Ravi
• University of Pittsburgh

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Male Brain vs. Female Brain

• Different in external anatomical and primary and
  secondary sexual differences
• There are also differences in the way male and
  female brains process language, information,
  emotion, cognition, etc (3).

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Differences

• Male Brain

• Female Brain

• Better in Mathematical calculations, etc.
• Higher than females in independence, dominance,
  spatial and mathematical skills, rank-related
  aggression, and other characteristics (3).

• Better in human relations.
• Higher than males in empathy, verbal skills,
  social skills, and security seeking (3).

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Physiological Differences

• Brain region in cortex discovered by scientists
  in Johns Hopkins University inferior-parietal
  lobule (IPL).
• Significantly larger in men than in women.
• This area is bilateral and located just above the
  parietal cortex (above the level of the ears).
• Left IPL larger for men, while right IPL larger
  for women.
• Women have more grey matter volume than do men
  (3).

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Regions other than the Cortex

• the volume of a specific nucleus in the
  hypothalamus (third cell group of the
  interstitial nuclei of the anterior hypothalamus)
  is twice as large in heterosexual men than in
  women and homosexual men, thus prompting a heated
  debate whether there is a biological basis for
  homosexuality (3).

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Headaches

• Common medical problem by any standard
• Represents most common reason for referral for
  Neurologists (2).

• Types
• Migrane
• Tension
• Cluster

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Migraine

• Migrainedisorder of sensory dysmodulation (2).
• Most common of the disabling primary headaches
• Represents 90 of headache complaints
• Pathophysiology inherited problem (2).
• Thus far, 3 genes for familial hemiplegic
  migraine identified
• Each involve dysfuntion of ion channels.

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Headaches in Women

• Women have headaches more commonly than men.
• Prevalence of migraine 18 of women and 6 of
  men.
• Estrogen levels are a key factor in increased
  prevalence of migraine in women (1).

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Evidence of the Effect of Estrogen levels on
Migraines

• Migraine prevalence increases at menarche
• Estrogen withdrawal during menstruation is a
  common trigger for migraine
• Estrogen administration in oral contraceptives
  and hormone replacement therapies can also
  trigger migraines.
• Migraines decrease during the 2nd and 3rd
  trimesters of pregnancy when estrogen levels are
  high
• Migraines are common immediately postpartum, with
  the precipitous drop in estrogen levels
• Migraines generally improve with physiological
  menopause (1).

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Effects of Estrogen levels (1).

• Fluctuations of estrogen levels can result in
• Changes in prostaglandins and the uterus
• Prolactin release
• Opioid regulation
• Melatonin secretion
• Changes in neurotransmitters
• I.e. Catecholamines, noradrenaline, serotonin,
  dopamine, and endorphins.

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Lifetime Prevalence of Headaches in Women and Men
(1).
Type Women Men
Any Headache 99 93
Migraine 25 8
Tension 88 69
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Important Headache Issues to be Covered (1).

• Menstrual Migraine
• Menopause and Migraine
• Oral Contraceptive Use in Migraineurs
• Headaches during Pregnancy and Postpartum

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Menstrual Migraine (1).

• Prevalence varies from 4 to 73
• Menstruation is trigger for about 60 of
  migraineurs.
• Symptoms of premenstrual syndrome include
  depression, anxiety, crying spells, difficulty
  thinking, lethargy, backache, breast tenderness,
  swelling, and nausea.
• Both Migraine and tension-type headaches can be
  associated.

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Management of Menstrual Migraine (1).

• Symptomatic treatment same as for other migraines
  NSAIDs (nonsteroidal antiinflammatory drugs)
  ergotamine, dihydroergotamine, and triptans.
• Premenstrual preventive treatment can be helpful
  for women with frequent migraines or with
  menstrual migraines that are severe and
  prolonged.

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Management of Menstrual Migraine (1)gt

• Effective Hormonal treatments
• Transdermal estradiol
• Bromocriptine 2.5mg, three times a day
• Danazol 200mg, two or three times a day
• Tamoxifen 5 to 15mg daily for days 7-14 of the
  luteal cycle.
• Hysterectomy is NOT RECOMMENDED for the
  management of menstrual migraine.

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Menopause and Migraines (1).

• 2/3rds of women with prior migraine improve with
  physiological menopause.
• Contrastingly, surgical menopause results in the
  worsening of migraine in 2/3rds of cases.

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Menopause and Migraines Estrogen Replacement
Therapy (1).

• Effect of hormone replacement therapy 45
  improve, 46 worsen, and 9 are unchanged.

Treatment of Estrogen replacement headache
Reduce estrogen dose
Change estrogen type from conjugated estrogen (Premarin) to pure estrone (Ogen)
Convert from interrupted to continuous dosing
Convert from oral to parenteral dosing (Alora, Climara, Estraderm, or Vivelle-Dot)
Add Androgens
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Oral Contraceptive Use and Migraine (1).

• Migraines may occur for the first time following
  oral contraceptive use
• OCs effect on migraines is quite variable
  migraines may increase, decrease, or stay the same

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OC Use and Migraines Risk of Stroke (1).

• Stroke in Young Women
• Annual occurrence of stroke in young women who
  take OCs is about 4 in 100,000 for women aged
  25-34 and 11 in 100,000 in women aged 35-44.
• For women who do not have migraine and do not
  take OCs 1.3 in 100,000 in women aged 25-34 and
  3.6 in 100,000 for women aged 35-44.
• Stroke and Migraine
• Increased risk of stroke in women with migraine

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Approximate Risk of Stroke in Young Women not on
OC with and without migraine (1).
Approximate incidence of ischemic stroke (strokes per 100,000 women per year) in women with and without migraine who do not use oral contraceptives. Approximate incidence of ischemic stroke (strokes per 100,000 women per year) in women with and without migraine who do not use oral contraceptives. Approximate incidence of ischemic stroke (strokes per 100,000 women per year) in women with and without migraine who do not use oral contraceptives. Approximate incidence of ischemic stroke (strokes per 100,000 women per year) in women with and without migraine who do not use oral contraceptives.
Migraine Migraine
Age Without Migraine Without Aura With Aura
25-34 1.3 4 8
35-44 3.6 11 22
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OC Use and Migraines Stroke and Use of OCs (1).

• Risk of stroke associated with OCs vary with
  different doses of estrogen.
• Recent studies have not shown an increased risk
  of stroke in women who use low-estrogen-dose OCs.
• OCs containing only progesterone do not increase
  the risk of stroke.

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OC Use and Migrane Use of Oral Contraceptives
in Migraneurs (1).

• Most recent OC use and stroke studies reveal no
  increased risk of stroke in OC use in
  migraineurs.
• Most women with migraine without aura and those
  with auras such as visual symptoms lasting less
  than one hour can use OCs.
• Women with aura symptoms such as hemiparesis or
  dysphasia or prolonged focal neurological
  symptoms and signs lasting more than one hour
  should avoid low-dose-estrogen Ocs.
• Progesterone-only OCs and many other
  contraceptive options may also be considered as a
  replacement.

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Headaches during Pregnancy and Postpartum (1).

• About 90 of headaches during pregnancy and
  postpartum are BENIGN.
• Frequency of migraines decreases and that of
  tension-type headaches does not change.
• Life threatening causes of headache that can
  occur during this time Preeclampsia and
  eclampsia, subarachnoid hemorrhage, intracerebral
  hemorrhage, and cerebral venous thrombosis.

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Migraine during Pregnancy and Postpartum (1).

• Occurs in 1 and 10 of migraineurs during
  pregnancy, usually during the first trimester.
• During pregnancy, preexisting migraine improves
  or disappears in about 60 or more, is unchanged
  in 20 or less, and grows more frequent in 20 or
  less. Improvement often occurs in 2nd or 3rd
  trimester.

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Migraine during Pregnancy and Postpartum (1).

• When improvement occurs during the first
  pregnancy, improvement also occurs during
  subsequent pregnancies in about 50, whereas an
  increased frequency occurs in the other 50.
• Migraneurs do not have an increased risk of
  miscarriages, toxemia, congenital anomalies, or
  stillbirth.

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Management (1).

• Fortunately, migraines usually improve or
  disappear during pregnancy.
• Nonmedication approaches avoidance of triggers,
  ice, sleep, and biofeedback.
• Symptomatic Medications Acetaminophen
• FDA Class B drug (no evidence of risk in humans,
  but no controlled human studies)
• Caffeine in small doses of less than 300mg a day
  is Class B and safe.
• Codeine in reasonable amounts is probably safe
• Triptans should be AVOIDED during pregnancy.

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Preventive Medications (1).

• Valproic acid to be avoided (Class D)
• Topiramate (Class C) should only by used if
  benefits outweigh risks.
• Preventive of choice Beta-blockers
• Calcium channel blocker verapamilsafe during
  pregnancy
• Antidepressants may be considered in some cases.

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References

1. Evans, Randolph W. Headache in Women. Pages
   230-240. Handbook of Headache 2nd ed, 2005.
2. Goadsby, Peter. Update in Headache. Page 140.
   2008 AAN Timeline Neurology Update II,2008.
3. Sabbatini, Dr. Renato M.E. Are There Differences
   Between the Brains of Males and Females? State
   University of Campinas 1997. lthttp//www.cerebrom
   ente.org.br/n11/mente/eisntein/cerebro-homens.html
   gt.

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Dedicated to my family for making everything
worthwhile
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READ not to contradict or confute Nor to Believe
and Take for Granted but TO WEIGH AND CONSIDER
THANK YOU