48-year-old woman with migraine with aura and menstrual

1
48-year-old woman with migraine with aura and
menstrual sinus headaches
CLINICAL CASE

• Presented by
• Anne MacGregor
• Barts Sexual Health Centre,
• St. Bartholomews Hospital, London, UK

2
IDENTIFICATION

• 48-year-old woman with migraine with aura and
  menstrual sinus headaches
• A common misdiagnosis of menstrual migraine
  without aura in a woman with migraine with aura

3
CASE PRESENTATION (I)

• SR is a 48-year-old magazine editor who has
  disabling attacks of migraine with aura and
  menstrual sinus headaches
• Attack frequency
• Migraine with aura every 4-6 weeks
• Sinus headaches with menstruation

4
CASE PRESENTATION (II)

• Description of migraine with aura
• Fortification spectra lasting 20-30 minutes
• Unilateral headache associated with photophobia
  and nausea lasting one day
• Description of sinus menstrual headaches
• Onset of sinus congestion followed by frontal
  headache associated with photophobia and nausea
  lasting two to three days
• No purulent nasal discharge afebrile

5
CASE PRESENTATION (III)

• Periods irregular and unpredictable 5/22-35 days
• Menstrual headaches disabling
• Occasional cramps on day 1

6
CASE PRESENTATION (IV)

• Treatment for migraine
• Frovatriptan 2.5 mg at onset of aura
• No more effective than ibuprofen
• Treatment for sinus headaches
• Nasal decongestant
• No longer effective
• Ibuprofen
• Partly effective but only if taken early

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PAST CLINICAL HISTORY (I)

• Headaches
• First attack of migraine with aura aged 12
• Sinus headaches that resolved in her 20s
• Sinus headaches returned 6 years ago associated
  with menstrual but less of a problem until
  periods became unpredictable

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PAST CLINICAL HISTORY (II)

• Takes the progestogen-only pill
• Combined hormonal contraceptives contraindicated
  because of migraine with aura
• Three pregnancies
• Migraine continued unchanged

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PAST CLINICAL HISTORY (III)

• Depression and anxiety
• Rx sertraline
• Otherwise healthy
• Systems review normal

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FAMILY HISTORY

• Parents
• Mother well no medical complaints
• Father died from prostate cancer Hx migraine
  with aura
• Siblings
• Younger brother migraine with aura
• Older sister no medical complaints

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PHYSICAL EXAMINATION

• On examination she looks in good health
• Physical examination and neurological assessments
  were unremarkable
• BP 120/75 mmHg
• BMI 26.7 kg/m2

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DIAGNOSTIC PROCEDURES

• None indicated
• No atypical features in the history
• Physical and neurological examinations normal

http//tools.aan.com/professionals/practice/pdfs/g
l0088.pdf
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DIAGNOSIS (I)

• Does she have migraine with aura?
• SR describes fully reversible visual
  fortification spectra followed by headache
  associated with nausea, photophobia and
  disability
• She is free of symptoms between attacks
• Normal physical and neurological examination
• This suggests a diagnosis of migraine with aura

Cephalalgia 201333 629-808.
14
DIAGNOSIS (II)

• What are the sinus headaches?
• SR describes episodic headache associated with
  nausea, photophobia and disability with complete
  freedom from symptoms between attacks
• Associated sinus congestion but no nasal
  discharge
• This suggests a diagnosis of migraine without aura

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DIAGNOSIS (III)

• Attacks of migraine without aura occur regularly
  with menstruation
• She has attacks of migraine with aura at other
  times of the cycle
• This suggests a diagnosis of menstrually-related
  migraine without aura (Fig. 1)
• Diary cards can confirm the diagnosis

Cephalalgia 201333 629-808.
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Figure 1 ICHD III MENSTRUALLY-RELATED MIGRAINE

• A. Attacks, in a menstruating woman, fulfilling
  criteria for Migraine without aura and criterion
  B below
• B. Documented and prospectively recorded evidence
  over at least three consecutive cycles has
  confirmed that attacks occur on day 1 2 (i.e.
  days -2 to 3) of menstruation in at least two
  out of three menstrual cycles, and additionally
  at other times of the cycle
• Notes
• 1. For the purposes of ICHD-3 beta, menstruation
  is considered to be endometrial bleeding
  resulting from either the normal menstrual cycle
  or from the withdrawal of exogenous progestogens,
  as in the use of combined oral contraceptives or
  cyclical hormone replacement therapy.
• 2. The first day of menstruation is day 1 and the
  preceding day is day -1 there is no day 0

Cephalalgia 201333 629-808.
17
DIAGNOSIS (III)

• Diary shows (Fig. 2)
• Migraine without aura starting on day 1 of
  menstruation duration 3 days
• Migraine with aura unrelated to menstruation
  duration 1 day

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Figure 2 THE PATIENTS HEADACHE DIARY
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TREATMENT (I)

• What is her current treatment and is she taking
  it optimally?
• Migraine with aura
• SR takes frovatriptan at onset of aura optimal
  time is onset of headache
• Menstrual migraine
• Correct diagnosis of migraine and failed response
  to analgesics merits consideration of a triptan

20
TREATMENT (II)

• Are there any relevant non-hormonal triggers?
• Identification of non-hormonal triggers are
  important, even for women with pure menstrual
  migraine. This is importnat because most attacks
  are the result of several triggers building up
  over the cycle.

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Figure 3 TRIGGER THRESHOLD
MacGregor EA. Cephalalgia 19961611-21
22
TREATMENT (III)

• Would she benefit from daily prophylaxis?
• Depends on attack frequency and response to acute
  treatment
• For women who have frequent attacks throughout
  the month, it is worth considering a daily
  prophylactic treatment in addition to acute
  medication, particularly if the response to acute
  medication is poor

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TREATMENT (IV)

• Treatment management
• Symptomatic treatment migraine with aura
• Recommend frovatriptan at onset of headache, not
  onset of aura
• Symptomatic treatment menstrual attacks
• Recommend frovatriptan at onset of headache,
  repeating for relapse of long-duration attacks
• Diary records for three months
• Consider non-hormonal triggers

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FOLLOW-UP

• Review diary cards to confirm diagnosis of
  menstrually-related migraine (Fig. 4)
• Review efficacy of acute treatment and consider
  need for prophylaxis (Fig. 5)

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Figure 4 ASSOCIATION BETWEEN MIGRAINE AND
MENSTRUATION
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Figure 5 ACUTE TREATMENT WITH FROVATRIPTAN
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TREATMENT EVALUATION

• Diary shows that menstrual attacks respond to
  frovatriptan and that she treats symptoms as soon
  as headache starts and repeats for relapse
• Headache and associated symptoms of migraine with
  aura respond to frovatriptan taken at onset of
  headache

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CLINICAL EVALUATION

• Diary confirms menstrual irregularity
• Bright sunlight and dehydration were identified
  as modifiable triggers for migraine with aura
• Daily prophylaxis is not indicated given her
  frequency of attacks and response to acute
  treatment

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REMARKS (I)

• Menstrual irregularity is common during the
  perimenopause and can be a challenge for
  effective management of menstrual migraine
• Migraine without aura commonly misdiagnoses as
  sinus headache

MacGregor EA. Curr Pain Headache Rep.
200913399-403 Schreiber CP, et al. Arch Intern
Med 20041641769-72 MacGregor EA, et al.
Neurology 2006672159-2163.
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REMARKS (II)

• Early treatment improves efficacy and reduces
  pain and functional disability
• Triptans should be taken at the onset of migraine
  headache, not onset of migraine aura
• Comorbid depression and anxiety can be treated
  with an SSRI without significant risk of
  serotonin syndrome

Cady R, et al. Curr Med Res Opin
2004201465-72 Bates D, et al. Neurology.
1994441587-92 Olesen J, et al. Eur J Neurol.
200411671-7 Dowson A. Eur Neurol.
199636(Suppl. 2)28-31 Gilman PK. Headache
201050264-72.
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REMARKS (III)

• Frovatriptan is effective for menstrual and
  non-menstrual migraine
• Long-duration attacks, such as menstrual
  migraine, need long-duration treatment, such as
  frovatriptan
• Diary cards are essential to confirm the
  diagnosis and assess the effects of treatment

Cortelli P, et al. Neurol Sci 32 Suppl 1S95-98
Allais G, et al. Neurol Sci 201132 Suppl
1S99-104 Sarchielli P, et al. J Headache Pain
201213(Suppl2)S31-70 Geraud G, et alHeadache
200343376-88 Evers S, et al. Eur J Neurol
200916968-81 Bendtsen L, et al. J Headache
Pain 13 2012 Suppl1S1-29.