Headache and Migrane in Women Prof. Dr. A.V. SRINIVASANM.D., D.M., Ph.D (Neuro), F.A.A.N., F.I.A.N,Professor in NeurologyInstitute of Neurology, MMC & GGH Samyuktha Ravi University of Pittsburgh
Male Brain vs. Female Brain • Different in external anatomical and primary and secondary sexual differences • There are also differences in the way male and female brains process language, information, emotion, cognition, etc (3).
Differences Male Brain Female Brain • Better in Mathematical calculations, etc. • Higher than females in independence, dominance, spatial and mathematical skills, rank-related aggression, and other characteristics (3). • Better in human relations. • Higher than males in empathy, verbal skills, social skills, and security seeking (3).
Physiological Differences • Brain region in cortex discovered by scientists in Johns Hopkins University: inferior-parietal lobule (IPL). • Significantly larger in men than in women. • This area is bilateral and located just above the parietal cortex (above the level of the ears). • Left IPL larger for men, while right IPL larger for women. • Women have more grey matter volume than do men (3).
Regions other than the Cortex • the volume of a specific nucleus in the hypothalamus (third cell group of the interstitial nuclei of the anterior hypothalamus) is twice as large in heterosexual men than in women and homosexual men, thus prompting a heated debate whether there is a biological basis for homosexuality (3).
Headaches • Common medical problem by any standard • Represents most common reason for referral for Neurologists (2). • Types: • Migrane • Tension • Cluster
Migraine • Migraine—disorder of sensory dysmodulation (2). • Most common of the disabling primary headaches • Represents 90% of headache complaints • Pathophysiology: inherited problem (2). • Thus far, 3 genes for familial hemiplegic migraine identified • Each involve dysfuntion of ion channels.
Headaches in Women • Women have headaches more commonly than men. • Prevalence of migraine: 18% of women and 6% of men. • Estrogen levels are a key factor in increased prevalence of migraine in women (1).
Evidence of the Effect of Estrogen levels on Migraines • Migraine prevalence increases at menarche • Estrogen withdrawal during menstruation is a common trigger for migraine • Estrogen administration in oral contraceptives and hormone replacement therapies can also trigger migraines. • Migraines decrease during the 2nd and 3rd trimesters of pregnancy when estrogen levels are high • Migraines are common immediately postpartum, with the precipitous drop in estrogen levels • Migraines generally improve with physiological menopause (1).
Effects of Estrogen levels (1). • Fluctuations of estrogen levels can result in: • Changes in prostaglandins and the uterus • Prolactin release • Opioid regulation • Melatonin secretion • Changes in neurotransmitters • I.e. Catecholamines, noradrenaline, serotonin, dopamine, and endorphins.
Important Headache Issues to be Covered (1). • Menstrual Migraine • Menopause and Migraine • Oral Contraceptive Use in Migraineurs • Headaches during Pregnancy and Postpartum
Menstrual Migraine (1). • Prevalence varies from 4% to 73% • Menstruation is trigger for about 60% of migraineurs. • Symptoms of premenstrual syndrome include: depression, anxiety, crying spells, difficulty thinking, lethargy, backache, breast tenderness, swelling, and nausea. • Both Migraine and tension-type headaches can be associated.
Management of Menstrual Migraine (1). • Symptomatic treatment same as for other migraines – NSAIDs (nonsteroidal antiinflammatory drugs) –ergotamine, dihydroergotamine, and triptans. • Premenstrual preventive treatment can be helpful for women with frequent migraines or with menstrual migraines that are severe and prolonged.
Management of Menstrual Migraine (1)> • Effective Hormonal treatments • Transdermal estradiol • Bromocriptine 2.5mg, three times a day • Danazol 200mg, two or three times a day • Tamoxifen 5 to 15mg daily for days 7-14 of the luteal cycle. • Hysterectomy is NOT RECOMMENDED for the management of menstrual migraine.
Menopause and Migraines (1). • 2/3rds of women with prior migraine improve with physiological menopause. • Contrastingly, surgical menopause results in the worsening of migraine in 2/3rds of cases.
Menopause and Migraines: Estrogen Replacement Therapy (1). • Effect of hormone replacement therapy: 45% improve, 46% worsen, and 9% are unchanged.
Oral Contraceptive Use and Migraine (1). • Migraines may occur for the first time following oral contraceptive use • OC’s effect on migraines is quite variable: migraines may increase, decrease, or stay the same
OC Use and Migraines: Risk of Stroke (1). • Stroke in Young Women • Annual occurrence of stroke in young women who take OCs is about 4 in 100,000 for women aged 25-34 and 11 in 100,000 in women aged 35-44. • For women who do not have migraine and do not take OCs: 1.3 in 100,000 in women aged 25-34 and 3.6 in 100,000 for women aged 35-44. • Stroke and Migraine • Increased risk of stroke in women with migraine
Approximate Risk of Stroke in Young Women not on OC with and without migraine (1).
OC Use and Migraines: Stroke and Use of OCs (1). • Risk of stroke associated with OCs vary with different doses of estrogen. • Recent studies have not shown an increased risk of stroke in women who use low-estrogen-dose OCs. • OCs containing only progesterone do not increase the risk of stroke.
OC Use and Migrane: Use of Oral Contraceptives in Migraneurs (1). • Most recent OC use and stroke studies reveal no increased risk of stroke in OC use in migraineurs. • Most women with migraine without aura and those with auras such as visual symptoms lasting less than one hour can use OCs. • Women with aura symptoms such as hemiparesis or dysphasia or prolonged focal neurological symptoms and signs lasting more than one hour should avoid low-dose-estrogen Ocs. • Progesterone-only OCs and many other contraceptive options may also be considered as a replacement.
Headaches during Pregnancy and Postpartum (1). • About 90% of headaches during pregnancy and postpartum are BENIGN. • Frequency of migraines decreases and that of tension-type headaches does not change. • Life threatening causes of headache that can occur during this time: Preeclampsia and eclampsia, subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral venous thrombosis.
Migraine during Pregnancy and Postpartum (1). • Occurs in 1% and 10% of migraineurs during pregnancy, usually during the first trimester. • During pregnancy, preexisting migraine improves or disappears in about 60% or more, is unchanged in 20% or less, and grows more frequent in 20% or less. Improvement often occurs in 2nd or 3rd trimester.
Migraine during Pregnancy and Postpartum (1). • When improvement occurs during the first pregnancy, improvement also occurs during subsequent pregnancies in about 50%, whereas an increased frequency occurs in the other 50%. • Migraneurs do not have an increased risk of miscarriages, toxemia, congenital anomalies, or stillbirth.
Management (1). • Fortunately, migraines usually improve or disappear during pregnancy. • Nonmedication approaches: avoidance of triggers, ice, sleep, and biofeedback. • Symptomatic Medications: Acetaminophen • FDA Class B drug (no evidence of risk in humans, but no controlled human studies) • Caffeine in small doses of less than 300mg a day is Class B and safe. • Codeine in reasonable amounts is probably safe • Triptans should be AVOIDED during pregnancy.
Preventive Medications (1). • Valproic acid to be avoided (Class D) • Topiramate (Class C) should only by used if benefits outweigh risks. • Preventive of choice: Beta-blockers • Calcium channel blocker verapamil—safe during pregnancy • Antidepressants may be considered in some cases.
References • Evans, Randolph W. Headache in Women. Pages 230-240. Handbook of Headache 2nd ed, 2005. • Goadsby, Peter. Update in Headache. Page 140. 2008 AAN Timeline: Neurology Update II,2008. • Sabbatini, Dr. Renato M.E. Are There Differences Between the Brains of Males and Females? State University of Campinas 1997. <http://www.cerebromente.org.br/n11/mente/eisntein/cerebro-homens.html>.
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