Women and Headaches: What You Need to Know

1. Women and Headaches: What You Need to Know

2. How Many People Have Migraine? • 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 American Migraine Study II National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment

3. Headache Diagnosis Of people who seek help for their headaches, most have migraine Source: Landmark Study

4. 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

5. 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

6. Basilar migraine Sinus headache Migraine with/without aura Chronic migraine Benign headache Tension-type Vascular headache Primary headache Ice pick Cluster Aura without headache Menstrual headache Mixed headache Migrainous The Doctor’s Perspective Physicians have many specific terms to explain the variety of headache types.

7. Nausea Vomiting Diarrhea Sweating Cold hands Light sensitivity Dizziness Neck pain Sensitivity to sound Scalp tenderness Pale complexion Pulsating temple Pressure pain Vertigo Difficulty thinking/concentrating What You May Feel Before or During an Attack

8. 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

9. Your Symptoms May Affect The Choice of Medication

10. 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

11. 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.

12. 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

13. Migraine Triggers Weather Alcoholic beverages Changes in sleep habit Hormonal changes Stress Glare or flickering light

14. 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

15. Definitions • Menstrual Migraine (7-8%) • Menstrually-related migraine

16. Menstrual Migraine • Keep a diary for three or four months • Learn which days you are at risk • Make a treatment plan • Follow over time

17. 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?

18. Treatment Options • Medications • Lifestyle adjustments • Diet • Exercise • Regular sleep pattern

19. Treatment Options • Give treatment for days at risk (focal use medication) • Options • NSAID/anti-inflammatory drugs (eg, ibuprofen) • DHE nasal spray or injection • Triptans

20. 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

21. 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

22. 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)

23. 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

24. 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

25. Oral Contraceptives and Migraine • Avoid triphasic pills • Watch for changing symptoms • Limit risk factors • Monitor headache diary

26. Sex Headaches • Need to see a doctor for appropriate work-up • Indomethacin • Beta-blockers

27. 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

28. 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

29. 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.

30. 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

31. 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.

32. 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

33. 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.

34. World Health Organization “Drugs may be considered safe in pregnancy if they have not been proven dangerous.”

35. Resources for At-risk Pregnancy • Genetic pharmacologist (counselor) • OB • Patient and significant other • Headache consultant

36. 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 • Will start an important dialogue about the appropriate course of action

37. What You Can Do • Rest • Biofeedback • Ice/heat • Massage • Avoidance of trigger • Exercise

38. Breast Feeding Soranus of Ephesus (150 A.D.) warned wet nurses to avoid drugs and alcohol lest it harm the nursing infant.

39. 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

40. Therapies that Target One Part of the Body • Trigger point injections • Nerve blocks • Physical therapy • Lidocaine (nasal or through the skin)

41. 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

42. Depression Sleep disturbance Changes in thinking/attention Heart disease Thin skin Urinary Incontinence Osteoporosis Vaginal dryness Abnormal bleeding Difficult or painful coitus Libido Less frequent migraine Menopausal Changes

43. 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

44. BETTER Spontaneous menopause 67% Surgical menopause 33% WORSE Spontaneous menopause 9% Surgical menopause 67% Menopausal Changes

45. 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?

46. 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

47. 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

48. If one product does not work…try another • Within the same class of drug • In a different class

49. Act like estrogen in the body Do not appear to increase risk of breast cancer May decrease blood pressure May decrease the amount of fats circulating in the blood 50% of American women use some kind of alternative medicine Only one fourth of women are using HRT Alternatives to HRT: Phytoestrogens

50. Alternatives to HRT: Phytoestrogens • Ligans seed oil • Coumestins - red clover, sunflower seeds • Isoflavones - soy, legumes, garbanzo beans Examples