1. Women and Migraine

3. The Prevalence and Diagnosis of Migraine in a
Primary Care Setting –The Landmark Study
Background:
• To determine the prevalence and diagnosis of migraine in
patients presenting to primary care physicians (PCPs) with a
complaint of headache
Study Design:
• Prospective, multi-center, international study
• PCPs from 128 centers in 14 countries recruited 1203 patients
• Recruited patients consulting PCP with complaint of headache
• PCP diagnosed patients via customary practice
• Expert panel made final headache diagnoses for patients with a
new migraine diagnosis or a non-migraine diagnosis (n=377)
Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting; July 16-20,
2002; Lake Buena Vista, Fl.

4. Patients Presenting with Headache
Most Likely Have Migraine
Of 377 patients who returned diaries:
Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting; July 16-20,
2002; Lake Buena Vista, Fl.
Episodic Tension
Headache
3%
Migrainous
18%
Migraine
76%
Other
3%

5. Why Women and Migraine?
• Women have Migraine 3:1 compared to
men.
• In peak years (20 – 50) , Migraine affects
25% of women (1 in 4).
• Migraine will affect 40% of women by age
50.

6. Prevalence of Migraine
Age and Gender
 Peak prevalence at age 40 years
 Greatest impact on ages 25 to 55 years
Lipton RB, et al. Headache. 2001;41:646-657.
0
5
10
15
20
25
30
0 20 30 40 50 60 70 80 90
Age (years)
MigrainePrevalence(%)
Females
Males

7. Female Life Events That
Influence Migraine
• Menarche
• Menses
• Oral Contraception
• Pregnancy
• Lactation
• Menopause
• Hormone Therapy

8. Migraine and Menarche
• Females suffer from migraine at a 3:1 ratio to
males
• Beginning with puberty, migraine is more
common in girls
• Menstrually-associated migraine begins at
menarche in 33% of women
• 60-70% of female sufferers experience migraine in
association with menses
MacGregor EA. Neurologic Clinics. 1997;15(1):125-141.
Silberstein SD, Merriam GR. Neurology. 1991;41:786-793.
Benedetto C et al. Cephalalgia. 1997;17(suppl 20):32-34.

9. Menstrual Migraine: Definitions
• Menstrually-associated migraine (MAM):
– Women who experience attacks that occur both
perimenstrually and at other times of the month
– 60-70% of female migraineurs report a menstrual
relationship to their headaches
– MAM is also referred to as menstrually-related
migraine (MRM)
• Menstrual migraine (MM):
– Women who experience attacks that occur only
perimenstrually
– True menstrual migraine occurs in only 7-14% of
female migraineurs
Benedetto C et al. Cephalalgia. 1997;17(suppl 20):32-34.

10. Role of Estrogen
• Estrogen is a neuromodulator.
• A decrease in estrogen increases the
Trigeminal mechano- receptor field which
in turn increases pain perception and
increases cerebral vasoreactivity to
serotonin.

11. Role of Estrogen
• In other words, a decrease in
estrogen can precipitate migraine.

12. Hormone Levels During Menstrual Cycle
Adapted from Hatcher RA, Trussell J, Stewart, F. Contraceptive Tecnhology, 17th Revised Ed.
New York, NY. Ardent Media, Inc. 1998:Appendix, Figure 2.
HORMONAL FLUCTUATIONS DURING THE MENSTRUAL CYCLE
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Day of Cycle (day 0 is start of blood flow)
HormoneLevelsThroughoutCycle Follicular Phase Luteal Phase
Endocrine
Cycle
LH
FSH
E2
POvulation

14. Treatment of Menstrual Migraine
• Symptomatic
• Prophylactic
• Hormonal Manipulation

15. Migraine and
Oral Contraceptives

16. Migraine and Oral Contraception
• Concerning migraine, 1/3 stay same, 1/3
improve, and 1/3 worsen.
• Triphasic preparations may make migraine
worse due to fluctuating levels.
• Lowest dose of estrogen best for migraine.
• Progesterone only pills do not affect
migraine.

17. Migraine and Oral Contraception
• Biggest risk of migraine is during hormone
free period.
• Newer preparations like Nuvaring may be
better due to constant low dose estrogen
release.

18. Migraine and Oral Contraception
• New or persistent Headache
• New onset of migraine with aura.
• Prolonged aura
Red Flags

19. Migraine and Oral Contraception
• Risk of stroke in healthy female <45 is 5-10 / 100,000.
• Odds ratio(OR) with any migraine – 3
• OR with migraine with aura – 6
• OR with migraine and OC – 5 – 17 (migraine with aura
higher end)
• OR with migraine, smoking, and OC - 34
Risk of Stroke

20. Migraine During
Pregnancy

21. Impact of Pregnancy on Migraine
• 60-70% improvement in the frequency of
migraines, particularly in the 2nd and 3rd
trimesters
• 4-8% of women experience worsening of
symptoms
• Approximately 10% of migraine cases start
during pregnancy
• Pre-pregnancy headache pattern returns almost
immediately postpartum
• Independent of migraine type
Aube M. Neurology. 1999;53(S1):S26-S28.

22. Treatment of Migraine during
Pregnancy
• Treatment is challenging due to risk to
baby.
• Magnesium, B2, and CoQ10 are probably
safe.
• Otherwise need to weigh benefits vs risks.

23. Migraine and Lactation

24. Migraine and Lactation
• Generally medications safe during
pregnancy are safe during lactation.
• Notable exceptions are Benadryl and
Cyproheptadine.
• Triptans are still recommended to pump and
dump.

25. Migraine and
Menopause

26. Migraine and Menopause
• Preexisting Migraine
– improves - 8% - 36%
– worsens - 9% - 42%
– unchanged - 27% - 64%
• New Migraine may develop in 8% - 13%

27. Migraine and Menopause
• In perimenopause, headaches may be worse
due to fluctuating hormone levels.

28. Migraine and Hormone
Replacement Therapy

29. Migraine and HRT
• Migraines improved - 22%
• Migraines worsened - 21%
• Migraines unchanged - 57%
– migraines likely to be unchanged if natural
menopause had no effect on them
Hodson et al /2000

30. Update on Migraine
Chronic Daily Headache
• Typically is a bilateral, constant headache
which occurs nearly daily
• Can fluctuate in intensity and at times have
characteristics of migraine
• Are frequently “transformed migraine”

31. Update on Migraine
Chronic Daily Headache
• Typically associated with taking analgesic
medication on a daily basis (medication overuse
headache)
– acetaminophen, Excedrin, ibuprofen, butalbital,
Midrin, narcotics, and even the 5HT 1b/1d agonists
• Prophylactic medication will not work if analgesic
rebound present

33. Questions?
Dr. Jeffrey Frank, M.D.
Neurologist
Norton Neuroscience Institute
(502) 629-2602