Women and Headaches:

What You Need to Know

How Many People Have Migraine?
American Migraine Study II
 There are 28 million migraine sufferers age 12+ in the
United States
– 21 million women
– 7 million men
 One in 4 households has at least 1 migraine sufferer
 Most people with migraine are 25-55 years old

National Headache Foundation. American Migraine Study II: Migraine in the

United States: Burden of Illness and Patterns of Treatment
 Headache Diagnosis
Headache Expert Diagnosis Based on
Diary Review

Migraine
Tension
98% Secondary

0.4%

1%
Of people who seek help for their headaches,
most have migraine
Source: Landmark Study
 What is Migraine?
 Repeated attacks of headache
– More than 5 attacks lasting at least 4 hours each
– Moderately or severely painful
– Frequent or infrequent
– Last a few hours to a couple of days
 Often only one side of the head hurts
 Often experience loss of appetite, nausea,
and vomiting

World Federation of Neurology

 Patients Often Have More Than
One Type of Migraine Attack
 Morning migraines
 Long duration migraines
 Migraines with nausea/vomiting
 Slowly developing migraines
 Rapidly escalating migraines
 Menstrual migraines
 The Doctor’s Perspective
Physicians have many specific terms to explain
the variety of headache types.

 Basilar migraine  Primary headache

 Sinus headache  Ice pick
 Migraine with/without  Cluster
aura  Aura without headache
 Chronic migraine  Menstrual headache
 Benign headache  Mixed headache
 Tension-type  Migrainous
 Vascular headache
What You May Feel Before or
During an Attack
 Nausea  Sensitivityto sound
 Vomiting  Scalp tenderness
 Diarrhea  Pale complexion
 Sweating  Pulsating temple
 Cold hands  Pressure pain
 Light sensitivity  Vertigo
 Dizziness  Difficulty
 Neck pain thinking/concentrating
 Medicines to Stop a
Migraine Attack
 Non-prescription medications – use with care
and tell your doctor
– NSAIDs (eg, ibuprofen, naproxen)
– Aspirin, acetaminophen, caffeine combination
(avoid using more often than twice a week,
especially if using several agents or if you drink a
lot of coffee, tea, or caffeinated soda)
 Prescription medications
– Triptans
– Dihydroergotamine (DHE)
– Others
Your Symptoms May Affect The
Choice of Medication
Medication Type Pro Con

Oral (tablets) Easy to take Won’t work if you

are vomiting

Nasal spray Good for patient with Fewer

nausea/vomiting, easy medications
to use available in nasal
spray
Injection Works fast Needle
Other Factors Involved in the
Choice of Medication
 How fast it works
– Nasal spray allows for fast onset of migraine relief
 How long it keeps working
 Other conditions you may have
– Nasal sprays and injections provide fast relief of headache,
nausea, and sensitivity to sound
 Other medications you may be taking
 Most patients wait too long before taking medicine for
best relief
– Triptans are most effective in the first couple hours of an
attack
– DHE works at any time during the attack
 Fast Relief vs. Long-lasting Relief
 Injections yield the fastest relief
 A scientific study1 compared DHE injection
with an injectable triptan
– The triptan worked faster
– DHE worked longer, so fewer patients had a return
of their headaches
 Another study2 found that some triptans can
allow headache recurrence up to 40% of the
time
1. Winner P, et al. Arch Neurol. 1996;53:180-184.
2. Geraud G, et al. Headache. 2003;43:376-388.
 Non-oral Alternatives
 Nasal Sprays
– Dihydroergotamine (Migranal®)
– Sumatriptan (Imitrex®)
– Zolmitriptan (Zomig®)
 Injections
– Dihydroergotamine (D.H.E. 45®)
– Sumatriptan (Imitrex®)
 Nasal sprays are safe, effective alternatives
to oral medications
 Migraine Triggers

Weather

Alcoholic
beverages

Changes in
sleep habit

Hormonal
Stress changes

Glare or
flickering light
 Women and Migraine
 70% of women will have worsening headaches
associated with their menstrual cycle
 60% of women will report relief from their headaches
during pregnancy (may not be true)
 40% of women will have their first migraine during
pregnancy or shortly after delivery
 70% of women have few migraines after menopause
 Many women report worsening headaches around
menopause
 Definitions
 Menstrual Migraine (7-8%)
 Menstrually-related migraine
 Menstrual Migraine
 Keep a diary for three or four months
 Learn which days you are at risk
 Make a treatment plan
 Follow over time
 Frequently Asked Questions
 When should I see my doctor about my
headaches?
 How long should I try a medication
without relief before it’s considered
unsuccessful?
 What are my options for headache
relief?
 Treatment Options
 Medications
 Lifestyle adjustments
 Diet
 Exercise
 Regular sleep pattern
 Treatment Options
 Give treatment for days at risk (focal
use medication)
 Options
– NSAID/anti-inflammatory drugs (eg,
ibuprofen)
– DHE nasal spray or injection
– Triptans
Treatment of Menstrual Migraine:
Focal Use Medications
Start taking the medicine about 1 day
prior to usual symptoms
Use doses which will allow rescue
Keep diary to get timing down
Continue treatment until risk is over
Treatment of Menstrual Migraine:
Focal Use Medications
 Non-steroidal anti-inflammatory drugs
(NSAIDS)
 Dihydroergotamine
– Nasal spray (Migranal®) 2mg
 Rescue with 2 mg – begins to work within 30 minutes
– Injection (D.H.E. 45®) 1 mg
 Rescue with 1 mg – dose can be repeated ,as needed, at
1-2 hour intervals for up to 3 mg in 24 hours
 Treatment of Menstrual Migraine:
Focal Use Medications
 Triptans
– Sumatriptan (Imitrex®): 25 mg twice a day (rescue with 50 or 100 mg)

– Naratriptan (Amerge®): 1mg twice a day

– Zolmitriptan (Zomig®): 2.5 mg twice a day (rescue with 5 mg)
– Rizatriptan (Maxalt®): 5 mg twice a day (rescue with 10 mg)
– Almotriptan (AxertTM): 6.25 mg twice a day (rescue with 12.5 mg)
– Frovatriptan (Frova®): 2.5 mg twice a day
– Eletriptan (Relpax®): 20 mg twice a day (rescue with 40 mg)
Treatment of Menstrual Migraine:
Hormones
 Leuprolide 3.75 mg with
estrogen/progesterone replacement
 Bromocriptine 2.5-5.0 mg/day
 Danazol 200-600 mg/day—day 3
through day 28
 Tamoxifen 5-15 mg
Oral Contraceptives and Headache
 Older tablets often worsened
headaches
 Newer pills are often more tolerable
 Estrogen replacement during placebo-
days may help with menstrual migraine
 Uninterrupted pill packs up to 3 months
at a time can also reduce the frequency
of menstrual migraine
Oral Contraceptives and Migraine
 Avoid triphasic pills
 Watch for changing symptoms
 Limit risk factors
 Monitor headache diary
 Sex Headaches
 Need to see a doctor for appropriate
work-up
 Indomethacin
 Beta-blockers
 Hormones, Pregnancy, and
Headaches
 Treatment of women who insist on
taking the Pill:
– NSAID starting the 19th day of the Pill cycle
until the 2nd day after restarting the Pill
– Estrogen patch during week of placebo
– 3 to 4 consecutive packs
Some Drugs Can Interfere

With Fertility
 Impact of Migraine on Pregnancy
 Migraine itself does not change fertility
 Migraine does not interfere with
pregnancy or hurt the fetus

Aube M. Neurology 1999; 53(S1):S26-S28.

Silberstein SD. Neurologic Clinics 1997;15 (1): 209
-231
 Impact of Pregnancy on Migraine
 60-70% fewer migraines, particularly in
the 2nd and 3rd trimesters
 4-8% of women experience worsening
of symptoms
 About 10% of migraine cases start
during pregnancy
 The headache pattern returns to normal
almost immediately after birth

Aube M. Neurology 1999; 53(S1):S26-S28.

 Pregnancy and Headaches
 Some studies show that 60% of patients lose
headaches with pregnancy - may not be true
 May have increased headaches in first
trimester
 Breastfeeding: a 50/50 protection during
postpartum
 It is not appropriate to hope the problem will
go away
 Pregnancy and Headaches
 Migraine affects 25% of
women during the
childbearing years
 Migraine is influenced by
hormonal factors
 50% of pregnancies are
unplanned, so fetuses
may be exposed to
medications
Aube M. Neurology 1999; 53(S1):S26-S28.
Silberstein SD. Neurologic Clinics 1997;15(1):209-31.
Lipton et al. Headache, 2000:41:646-657.
The Pregnant Migraine Patient
 Pregnancy may produce symptoms
 How many women have migraine
during pregnancy is unknown
 Some studies show 60% improvement
during pregnancy
 Patients with more frequent headaches
may not improve during pregnancy
 Medication Use During Pregnancy
 International survey conducted by the
World Health Organization
– 86% of 14,778 pregnant women surveyed
took a prescription medication
– Each received an average of 3
prescriptions

Silberstein SD. Neurologic Clinics 1997;15(1):209-31.

 Maternal Use of Medications
 Pregnancy is a symptom-producing
event
 Women take more drugs during
pregnancy
 50% of pregnancies are unplanned
 Many medications, including DHE and
triptans, should not be used by
pregnant women or nursing mothers
World Health Organization

“Drugs may be considered safe in

pregnancy if they have not been
proven dangerous.”
Resources for At-risk Pregnancy
 Genetic pharmacologist (counselor)
 OB
 Patient
and significant other
 Headache consultant
 Genetic Pharmacologist
 Will
assess the overall risk of the couple
based on:
– Family history
– Age
– Spontaneous risk
 Will assess current medications to determine:
– Whether there is a need to stop taking a medicine
– The risk posed by the medicine in relation to the
benefit of continued use
 Willstart an important dialogue about the
appropriate course of action
 What You Can Do
 Rest
 Biofeedback
 Ice/heat
 Massage
 Avoidance of trigger
 Exercise
 Breast Feeding

Soranus of Ephesus (150 A.D.) warned

wet nurses to avoid drugs and alcohol
lest it harm the nursing infant.
 Breast Feeding
 Increasing popularity
 Drugs can be present in milk
 Pump and discard
 Effect on migraine is not known
 Most studies do not show change
 Medications and Mother’s Milk 2002
 Sumatriptan approved by the American
Academy of Pediatrics
 Therapies that Target One
Part of the Body
 Triggerpoint injections
 Nerve blocks
 Physical therapy
 Lidocaine (nasal or through the skin)
 What is Menopause?
 Sometimes called the climacteric
 A process, not a single event
– Hormone changes
– Ovaries stop producing eggs
– Hormonal cycling ends
 Many symptoms
 Average age is 51
 Most women can expect to live at least one-
third of their lives after menopause
 Menopausal Changes
 Depression  Osteoporosis
 Sleep disturbance  Vaginal dryness
 Changes in  Abnormal bleeding
thinking/attention  Difficult or painful
 Heart disease coitus
 Thin skin  Libido
 Urinary Incontinence  Less frequent
migraine
 Headache and Menopause
 70% of women lose their headaches
with menopause
 Worsening headaches around
menopause is not unusual
– May need a preventive medicine
– Early estrogen replacement therapy
 Menopausal Changes
 BETTER  WORSE
– Spontaneous – Spontaneous
menopause 67% menopause 9%
– Surgical – Surgical
menopause 33% menopause 67%
 Frequently Asked Questions
From Patients
 Will my headaches be better after
menopause?
 If I have headaches, can I take
hormone replacement therapy (HRT)?
 If I take HRT, does it matter what dose
and preparation I use?
 Can I still take triptans after
menopause?
 Decision to Use HRT
Should be Made Based on Factors Other Than Migraine
 Risk of osteoporosis
 Unpleasant symptoms
 Risk of breast cancer
 Heart disease risk factors
– New evidence casts doubt on the benefit of HRT
in heart disease
 Other considerations
 Cardiovascular Risk Factors
 Can we still use triptans?
 Patients have been excluded from
clinical trials after menopause
 Recommendations for safe use of our
migraine-specific drugs
If one product does not work…
try another
 Within the same class of drug
 In a different class
 Alternatives to HRT:
Phytoestrogens
 Act like estrogen in the  50% of American
body women use some kind
 Do not appear to of alternative medicine
increase risk of breast  Only one fourth of
cancer women are using HRT
 May decrease blood
pressure
 May decrease the
amount of fats
circulating in the blood
 Alternatives to HRT:
Phytoestrogens
Examples
 Ligans seed oil
 Coumestins - red clover, sunflower
seeds
 Isoflavones - soy, legumes, garbanzo
beans
 Botanicals Commonly Used
 Angelica  Evening primrose
 Licoriceroot  Black cohosh
 Ma huang  Blue cohosh
 Motherwort  Valerian
 Red clover  Dong quai
 Mettle  Ginseng
 Uva vis  Soy
 Conclusions
 Migraine headaches can be triggered by a
variety of things, including hormonal changes
 For menstrual migraine, focal use
medications can be helpful
 Your headache pattern may change with
menopause or pregnancy
 Many migraine drugs are present in breast
milk
 Many options are available for migraine relief
– ask your doctor what’s right for you
The National Headache Foundation
 For more information on headache causes
and treatments visit the National Headache
Foundation (NHF) Web site at:
www.headaches.org
 A list of NHF physician members by state is
available on request by calling toll-free:

1-888-NHF-5552