1. Prof. Dr. A.V. SRINIVASAN
M.D., D.M., Ph.D (Neuro)DSC(HON), F.A.A.N., F.I.A.N,
FORMER -Professor in Neurology and HEAD
Institute of Neurology, MMC & GGH
17-06-2011

2. 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).

3. Differences
Male Brain Female Brain
Better in Mathematical Better in human relations.
calculations, etc. Higher than males in
Higher than females in empathy, verbal skills, social
independence, dominance, skills, and security seeking
spatial and mathematical (3).
skills, rank-related
aggression, and other
characteristics (3).

4. 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).

5. 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).

6. Headaches
Common medical Types:
problem by any standard Migrane
Represents most Tension
common reason for Cluster
referral for Neurologists
(2).

7. 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.

8. 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).

9. 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).

10. 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.

11. Lifetime Prevalence of Headaches
in Women and Men (1).
Type Women Men
Any Headache 99% 93%
Migraine 25% 8%
Tension 88% 69%

12. Important Headache Issues to be
Covered (1).
Menstrual Migraine
Menopause and Migraine
Oral Contraceptive Use in Migraineurs
Headaches during Pregnancy and Postpartum

13. 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.

14. 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.

15. 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.

16. 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.

17. Menopause and Migraines:
Estrogen Replacement Therapy (1).
Effect of hormone Treatment of Estrogen replacement
headache
replacement therapy: Reduce estrogen dose
45% improve, 46% Change estrogen type from conjugated
worsen, and 9% are estrogen (Premarin) to pure estrone
(Ogen)
unchanged.
Convert from interrupted to
continuous dosing
Convert from oral to parenteral dosing
(Alora, Climara, Estraderm, or Vivelle-
Dot)
Add Androgens

18. 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

19. 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

20. Approximate Risk of Stroke in
Young Women not on OC with and
without migraine (1).
Approximate incidence of ischemic stroke (strokes per 100,000 women per
year) in women with and without migraine who do not use oral
contraceptives.
Migraine
Age Without Migraine Without Aura With Aura
25-34 1.3 4 8
35-44 3.6 11 22

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. References
1. Evans, Randolph W. Headache in Women. Pages
230-240. Handbook of Headache 2nd ed, 2005.
2. Goadsby, Peter. Update in Headache. Page 140.
2008 AAN Timeline: Neurology Update II,2008.
3. 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/eisnte
in/cerebro-homens.html>.

29. Dedicated to my family
for making everything worthwhile

30. READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOU