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Timothy C. Hain, MD, Chicago
IL.
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Page last modified:
January 11, 2013
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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.
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| 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). |
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 prevalance of roughly 30%.
There is reasonable evidence that the increased incidence of migraines in womenis caused by going from a high to a low estrogen state (Somerville, 1975; MacGregor et al, 2007). 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.
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, associated with drastic drops in estrogen, 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:
Abortive medications
Migraine often (77%) improves during pregnancy, especially in the 2nd and 3rd trimester (Sances et al, 2003). 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 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. Topamax should not be used because of a high incidence of cleft palate.
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).
Venlafaxine (for prevention of migraine) is generally thought to be safe in nursing mothers (see drugs.com site). Topamax 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".
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. 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.
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