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Hormonal Therapies for Migraine:
Risks vs. Benefits |
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BY MAURY BREECHER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
Hormonal therapies for migraine can be either preventative or
provocative, commented Dr. Vincent Martin on February 19 at an
annual headache course sponsored by the Diamond Headache Clinic
Research and Education Foundation.
Dr. Martin, a professor of medicine at the University of
Cincinnati, said the “femaleness of migraine is inescapable,”
and that up to four times as many females as males experience
migraine between the ages of 25 and 55, with the peak prevalence
occurring at age 40.
Migraines occur because of an imbalance between the human
neuroexcitatory and neuroinhibitory transmitter systems,
according to Dr. Martin. The most obvious trigger is estrogen
withdrawal. It’s during low levels of estrogen that increased
migraines occur.
“What we think happens is that when a women is in a high
estrogen state, the estrogen upregulates neuroexcitatory
neurotransmitter pathways, such as the glutamatergic system
within the trigeminal system,” he said in an interview following
his presentation. Dr. Martin further explained that he and other
researchers believe that estrogen also increases the activity of
certain descending neuroinhibitory pathways that counterbalance
the upregulation of neuroexcitatory systems.
He said researchers believe that when estrogen levels fall, the
glutamatergic changes involved don’t reverse as fast as
neuroinhibitory systems so there is a massive outpouring of
excitation that results in a migraine.
Some hormonal changes might actually be preventive, he
continued, speculating that an “umbrella of high estrogen and
progesterone that occurs in the midluteal phase may actually be
preventive, protecting some women from headache.”
That led Dr. Martin to discuss hormonal therapies using oral
contraceptives to regulate estrogen levels.
He talked first about the stroke risk of oral contraceptives. He
said migraine by itself is a slight risk factor for stroke. In
fact, relative risks for strokes are roughly double for
migraineurs compared with women without migraines. Female
patients with migraine with aura have a higher risk for stroke
than those who have migraine without aura—the risk is about 2½
to 4 times higher than women in the general population in the 20
to 50 age groups.
However, when a woman has other risk factors for stroke, such as
hypertension or smoking, her personal risk profile increases. If
you add oral contraceptives on top of those risk factors, the
risk might go up as much as 8 to 16 times than that of the
general population, said Dr. Martin.
For reasons like these, a number of authoritative medical bodies
recommend against using oral contraceptives in patients who have
migraine with aura. Other experts disagree, saying the risk of
oral contraceptives is still small for patients who have
migraine with aura and that the risk of unplanned pregnancy and
pregnancy-related health problems is actually greater.
If women with migraine want to use oral contraceptives and don’t
have a plethora of other risk factors, Dr. Martin evaluates them
for therapy. If they have migraine with aura, he tends to advise
them not to use oral contraceptives.
If they have migraine without aura, he most often will prescribe
a monophasic pill that has a fixed combination of ethinyl
estradiol (a high-potency synthetic estrogen that inhibits
gonadotropin release) and progestin. He then will cycle them
every 3 months so they have a period only three or four times a
year, thereby limiting monthly swings in estrogen levels.
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| Copyright 2008 Elsevier Custom Conference Coverage. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the copyright owner. No responsibility is assumed by the Publisher for any injury and/or damage to persons or property as a matter of products liability, through negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, the Publisher recommends that independent verification of diagnoses and drug dosages should be made. Opinions expressed in this publication are those of the original authors and do not necessarily reflect those of the Publisher, the sponsor, or the editors. Elsevier assumes no liability for any material published herein. |
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