MIGRAINE HEADACHE IN WOMEN

Timothy C. Hain, MD, Chicago IL. Return to Migraine main page. Page last modified: December 26, 2007

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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.

Women have more migraine 3 times more commonly than men because of hormonal fluctuations. There is reasonable evidence that the increased incidence of migraines is caused by going from a high to a low estrogen state (Somerville, 1975; MacGregor et al, 2007). Boys and girls prior to puberty have equal rates. Several special considerations apply to women.

Hormones: In women with migraine, birth control pills should be stopped and hormonal supplementation 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.

Lupron "cycling" therapy, often aggravates migraine, and if practical considering the entire health picture, it should be stopped.

Menstrual migraine

Increased headaches around menses are due to fluctuations in estrogen level (a withdrawal effect). Medications include:

Prophylactic medications:

Aspirin, Naproxen or Motrin, use a small dose for 3 days prior to anticipated menses (Sances et al, 1990)
Bromocriptine (2.5 mg tid) used continuously (Herzog, 1997) reduced headache occurrence by at least 25%. This study was not double-blinded.
Ponstel : (250 every 6 hours, not to exceed one week)
Diamox 250 mg: Twice a day, 3-4 days prior to menses
Magnesium (360 mg/day) was reported helpful in a small study (Facchinetti et al, 1991)
Estrogen patches (100 ug) was reported helpful (Pradalia et al, 1994)

Abortive medications

Acetaminophen plus aspirin plus caffeine. In a retrospective study, 61% of patients experienced headache relief with this combination compared to 29% taking placebo (Silberstein, 1999).
Triptans: Essentially, the message is the higher doses delivered quickly work the best.
- Amerge -- this triptan is sometimes used off-label to prevent menstrual migraine. Safety is not known.
- Frova -- this 24 hour triptan is also used similarly to Amerge.
- Sumatriptan --The subcutaneous form appears very effective (80% treated vs. 19% placebo) according to Solbach and Wayber (1995). Not only headache but nausea is reduced.
- Sumatriptan tablets (100 mg) are less effective
- Zolmatriptan is also less effective (69% vs. 42%) according to Schoenen et al (1997)
- Rizatriptan is similar (70% vs 44%) at 2 hrs according to Silberstein (2000)

Pregnancy and Migraine

Migraine often (77%) improves during pregnancy, especially in the 2nd and 3rd trimester (Sances et al, 2003). Most clinicians advise avoidance of medication when at all possible, using instead dietary modification, ice, or simply rest.

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 cannot 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.

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 should be avoided in pregnancy (because of bleeding potential

References:

Fancchinetti F and others. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache 1991:5:298-301
Herzog AG. Continuous bromocriptine therapy in menstrual migraine. Neurology 1997:48:101-2
MacGregor EA and others. Indicidence of migraine relative to menstrual cycle phases of rising and falling estrogen. Neurology 2006:67:2154-2158
Pradalier A and others. Correlation between estradiol plasma level and therapeutic effect on menstrual migraine. Proc 10th Migraine Trust Symp 1994:129-152
Sances G, and others. Naproxen sodium in menstrual migraine prophylaxis: a double-blind placebo controlled study. Headache 1990:30:705-9
Sances G, Granella F, Nappi R, Fignon A, Ghiotto N, Polatti F, Nappi G.Course of migraine during pregnancy and postpartum: a prospective study. : Cephalalgia 2003 Apr;23(3):197-205
Schoenen J, Sawyer I. Zolmitriptan (zomig) a novel dual central and peripheral 5HT1b/d agonist: an overview of efficacy. Cephalgia 1997:17(suppl 18) 28-40
Shuhaiber S, Pastuszak A, and others. Pregnancy outcome following first trimester exposure to sumatriptan. Neurology 1998:51:581-583
Silberstein and others, Clin Ther 1999:21:475-71)
Silberstein and others. rizatriptan in the treatment of menstrual migraine. Obstet Gynecol 2000:96:237-242
Solbach MP, Waymer RS. treatment of mensturation-associated migraine headache with subcutaneous sumatriptan. Obstet Gynecol 1995:82:769-772
Somerville BW, Estrogen-withdrawell migraine. Neurology 1975;25:239-250