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Perimenopausal Issues and
Migraine |
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BY MAURY BREECHER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
Although the prevalence of migraine attacks decreases as women
enter menopause and their estrogen levels decline, some women
experience even more severe migraines when their orderly pattern
of estrogen and progesterone secretion is lost, said Dr. Jan
Lewis Brandes on February 19 during a Headache Research Summit
sponsored by the Diamond Headache Clinic Research and Education
Foundation.
And although fluctuation of these hormones can cause dramatic
increases in both severity and frequency of migraine in those
women, many delay migraine treatment because they don’t realize
that their previous patterns of headache were migraines, pointed
out Dr. Brandes, an assistant clinical professor of neurology at
Vanderbilt University, Nashville (Brandes JL. The influence of
estrogen on migraine: A systematic review. JAMA.
2006;19;295(15):1814-1830).
After menopause, approximately two-thirds of women notice a
marketed improvement in their migraines. For instance, in a
group of 556 naturally menopausal women, 76 (14%) reported
headache compared to 82% who had reported headache symptoms
before menopause.
Sixty-two percent of the women who experienced migraine or
tension type headache before menopause reported abatement of
symptoms after menopause, indicating that as many as 38% of the
women were experiencing similar or worsening symptoms, said Dr.
Brandes.
Characteristics of women who experience migraine in menopause
typical include those who were younger at the onset of
menopause, who had surgically induced menopause, were smokers,
used alcohol daily, and who had a history of previous use of
oral contraception and current use of hormone therapy. In a
study of 17,107 postmenopausal women, current hormone therapy
use significantly increased the risk of experiencing a migraine
within the previous year compared with women without hormone
therapy use (13% vs. 9%, P<0.001).
Hormonal therapy should be considered when practitioners suspect
the migraines are being trigged by hormone fluctuations,
continued Dr. Brandes.
While therapeutic options should be individualized for women
with menopausal migraine, cyclic hormone replacement therapy may
be considered if breakthrough migraine responds easily and
quickly to moderate analgesics and/or triptans, and most
importantly does not interfere with activity, she advised.
However, cyclic hormone replacement may complicate therapy for
perimenopausal and menopausal migraineurs, Dr. Brandes added.
“For the woman whose migraine attacks are triggered by
fluctuation in estrogen and progesterone, initiation of cyclic
therapy may markedly worsen her migraine,” said Dr. Brandes.
If menstrual migraine is debilitating and unresponsive to
abortive therapy, other women may benefit from continuous
hormonal replacement therapy with combined estrogen and
progesterone (or estrogen alone, if the uterus has been
removed.).
“Too high or too low a dose may make them worse, but if you
appropriately maximize the estrogen dose, things should turn out
right,” said Dr. Brandes.
To ascertain the maximum dose, take the woman’s hormonal history
and have her keep a headache diary to determine the best dose
for her, advised Dr. Brandes.
Triptan therapy, in combination with NSAIDS, can be offered for
breakthrough migraine attacks. Newer regimens may include
extended use oral contraceptive pills to eliminate menstrual
periods and can be used to usher women from perimenopause into
menopause, according to Dr. Brandes.
Although hormonal treatment should be considered, many women
with moderate to severe migraine will not respond to hormone
replacement therapy, she continued. Others may worsen on HRT,
but may choose to remain on hormone replacement to prevent bone
loss or to minimalize miserable menopausal symptoms. In that
group of women, stated Dr. Brandes, conventional migraine
prophylactic treatment can be employed.
“Severe escalations in migraine should always prompt a search
for other causes or exacerbating factors of headache,” she
continued. “Those factors could include giant cell arteritis,
analgesic rebound headache, pituitary adenoma, as well as other
causes.”
Abortive regimens with migraine-specific triptans should be
employed for acute attacks, and patients should be educated
about the importance of early treatment, Dr. Brandes emphasized.
In patients for whom cardiovascular risks preclude the use of
triptans or ergots, dopamine antagonists combined with high-dose
NSAIDs, or even steroids, could be used as rescue treatments.
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