Timothy C. Hain, MD, Chicago IL. Return to Migraine main page. Page last modified: September 23, 2017
You may also be interested in our many other pages on migraine on this site
Migraines are recurrent headaches separated by symptom-free intervals and accompanied by nausea and light sensitivity. Migraines are often accompanied by visual symptoms and are relieved by sleep; furthermore there is usually a throbbing quality.
|Migraine prevalence vs age in women (dashed) and men (solid). (Stewart et al, 1994). The study that provided this data was according to age rather than time of menopause. This is probably the reason that this plot does not show the secondary peak in migraine that occurs perimenopausally (Macgregor and others).||Migraine by age in women and men, in the author's "dizzy" clinic practice. This graphic clearly shows that women have far more migraine than men, and also that the peak age is not 35 as in the general population, but rather is 50 in patients who go to the clinic for help with their dizziness (in both men and women).|
Women have more migraine 3 times more commonly than men. This is attributed to hormonal fluctuations. Boys and girls prior to puberty have equal rates. However, starting at roughly the age of 12, the prevalence of migraine in women takes an abrupt increase compared to men. The prevalence of migraine peaks in women in the middle of their reproductive years -- about the age of 35. There is also a second peak of migraine at the time of menopause (see below), where migraine in women has a prevalence of roughly 30%.
There is reasonable evidence that the increased incidence of migraines in women is caused by going from a high to a low estrogen state (Somerville, 1975; MacGregor et al, 2007; MacGregor 2015). As can be seen below, there are two points that this happens -- just after ovulation, and a few days prior to menstruation. Migraines typically diminish in women after roughly 4 years of menopause.
Migraines also typically diminish in pregnancy, when estrogen levels are high but fairly constant.
Several other special considerations apply to women.
|Estrogen levels throughout the menstrual cycle, adapted from Ibrahimi et al, 2015|
In women with migraine, ideally birth control pills that cause estrogen to fluctuate (i.e. with spacers) should be stopped. If hormones cannot be stopped, say because of endometriosis, then they should be changed to a constant amount every day. It often takes 2-3 months for the beneficial effects of hormonal manipulations to take effect.
Additionally, the use of oral contraceptives is generally contraindicated in women with migraine with aura (Allais, Gabellari et al. 2009). The risk of stroke is roughly 2-fold increased (Schurks, Rist et al. 2009). Non-estrogen containing birth control pills can be used safely in migraine with aura, according to Dodick (Dodick 2009). In other words, estrogen is to be avoided when possible in women with migraine with aura.
Lupron "cycling" therapy, associated with drastic drops in estrogen, often aggravates migraine, and if practical considering the entire health picture, it should be stopped.
Disregarding migraine entirely, Owada and Suzuki (2014) reported that menopause related dizziness is correlated with hot flashes. We agree.
Menstrual migraine (MM)
Increased headaches around menses are correlated with fluctuations in estrogen level (a withdrawal effect, see above). Strangely though, women with menstrual headaches are reported to have LESS fluctuation of both estradiol levels and the trigeminovascular vasodilator system than normal subjects (Ibrahimi et al, 2015). One would expect the opposite.
Medications used in a somewhat special way in MM include:
Prophylactic medications: (some of these are just used perimenstrually)
- Bromocriptine (2.5 mg tid) used continuously (Herzog, 1997) reduced headache occurrence by at least 25%. This study was not double-blinded, and we are dubious that this effect is real. We also are dubious that use of this medication is warranted in a benign condition such as migraine.
- Diamox 250 mg: Twice a day, 3-4 days prior to menses. We are again dubious.
- Magnesium (360 mg/day) was reported helpful in a small study (Facchinetti et al, 1991), and is generally accepted as useful in migraine in general. More recently, 500-600 mg is recommended.
Perimenstrual prophylactic medications
- Aspirin, Naproxen or Motrin, use a small dose for 3 days prior to anticipated menses (Sances et al, 1990)
- Estrogen patches (100 ug) was reported helpful (Pradalia et al, 1994). Macgregor (2015) suggests using 1.5mg patches starting between days -5 and 02 of menstruation for 7 days (a total of 7 days).
- Frovatriptan -- this 24 hour triptan is also used similarly to Amerge. Recently, extremely high pricing has made frovatriptan unaffordable to many.
- mefenamic acid (Ponstel) : (250 every 6 hours, not to exceed one week)
- Naratriptan (Amerge) -- this triptan is sometimes used off-label to prevent menstrual migraine. Safety is not known.
Abortive medications: These medications are used identically for migraine in general, look here for a discussion
It is generally thought that migraine often (77%) improves during pregnancy, especially in the 2nd and 3rd trimester (Sances et al, 2003). Some hold that migraine with aura does not improve. (Torelli et al, 2010). Most clinicians advise avoidance of migraine prevention medications, using instead dietary modification, ice, or simply rest. Botox injections would also seem to us to be a reasonable modality, as it is difficult to envision an effect of a local agent on the fetus. Acupuncture and some vitamins are also recommended by some, such as magnesium, riboflavin, and Co-Q10.(Airola, Allais et al. 2010). See this page for more information about how these are taken.
If medications are deemed necessary, it is generally felt that no migraine specific medications (like "ergots") should be used during pregnancy because of the danger of inducing early labor. Nevertheless, a recent report suggested that there is no difference in pregnancy outcome when sumatriptan is used in the first trimester (Shuhaiber et al, 1998). Preventive medications can generally not be used until the third trimester. Then some clinicians use amitriptyline or imipramine as both have a long record of safety during pregnancy. These should be withdrawn 2 weeks prior to estimated date of delivery. Inderal (propranolol) may reduce cardiac performance during delivery, and should be avoided if possible for this reason. Presumably the same considerations apply to all other beta blockers.
Topamax should not be used because of a high incidence of cleft palate. It is also well known that sodium valproate should be avoided entirely in pregnancy.
For pain, one may use acetaminophen (tylenol). Birth defects have not been attributed to acetaminophen after almost four decades of use worldwide. Aspirin and non-steroidal anti-inflammatory drugs should be avoided in pregnancy (because of bleeding potential).
Venlafaxine (for prevention of migraine) is generally thought to be safe in nursing mothers (see drugs.com site). Topiramate is not.
There is evidence that while migraine diminishes with age, there is often a flare in migraine perimenopausally (MacGregor and Barnes, 1999; MacGregor 2006; Wang et al, 2003). According to MacGregor (1999), about 30% of women in menopause experience migraine headache. This is similar to the prevalence reported in 35 year old women, and thus represents a second "peak". Owada and Suzuki (2014) reported that menopause related dizziness is correlated with hot flashes. We agree.
In the author's practice, a pattern of more headaches for about 4 years following onset of menopause is common, and usually diagnosed as migraine. Medication management is aimed at suppression of hormonal fluctuation (Loder et al, 2007), as well as drugs that reduce hot flashes (e.g. venlafaxine). HRT -- hormone replacement therapy -- consists of a combination of low-dose estrogen and medroxyprogesterone. The progresterone component is used in women who have an intact uterus to prevent uterine hyperplasia. This approach is generally not continued indefinately due to the potential for long term adverse effects, including increasing the risk of breast cancer.
Other drugs that may help manage the hot-flashes and headaches that are often combined include SSRI's (such as paroxetine and fluoxetine), SNRI's (such as venlafaxine in low doses), low-dose clonidine, and gabapentin.
Migraine prophylactic medications are often helpful for controlling the headache symptoms. We particularly favor venlafaxine in low doses for this purpose. Venlafaxine has two roles -- prevent migraine and prevent hot flashes.