Migraines in Women

We all have either experienced or know someone who is experiencing migraines, headaches or general neurology problems. Randolph W. Evans is helping general neurology problems with medical knowledge and personal experience. Randolph W. Evans, M.D is the director of the Neurology and Headache centre at the Park Plaza Hospital in Houston.

Women have headaches more commonly than men. The prevalence of migraine is 18% of women and 6% of men. There are issues specific to the treatment of female migraineurs. During pregnancy, the frequency of migraines decreases (especially during the second and third trimesters) in 60%, remains the same in 20%, and increases in 20%. Migraines may occur for the first time when women start using oral contraceptives (OCs). Low-estrogen OCs usually have no effect on migraine or may even improve it, although the frequency can increase. Of patients with new-onset migraine or increased frequency of migraine associated with OCs, 30 to 40% may improve when OCs are discontinued, although improvement may not occur for up to 1 year. Two thirds of women with prior migraine improve with physio-logic menopause. Surgical menopause results in worsening of migraine in two thirds of cases.

Menstrual migraine is treated with the same acute-treatment medications as other migraines. Interval or short-term preventive treatment of menstrual migraine, starting 2 or 3 days before menses and continuing during the menses, may be helpful for some women with regular menses and migraines that are poorly responsive to symptomatic medications. Potentially effective medications include the following: amitriptyline or nortriptyline, 25 mg at bedtime; long-acting propranolol, 60 to 80 mg daily, or nadolol, 40 mg daily; nonsteroidal antiinflammatory drugs (NSAIDS) such as naproxen sodium, 550 mg twice daily; ergotamine, 1 mg once or twice a day, or DHE, 1 mg subcutaneously or intramuscularly; naratriptan, 1 mg orally twice daily, or frovatriptan, 2.5 mg twice daily, for 6 days peri-menstrually; transdermal estradiol, 100 µg applied 3 days before the expected start of menses and replaced after 3 days; continuous combined OC use, with a lower estrogen dose given during the menses; and extended-duration OC use.

Although low-estrogen OCs may be associated with a small increase in ischemic stroke risk, most women who have migraine without aura can safely take low-estrogen OCs if they have no other contraindications or risk factors. When taking low-estrogen OCs, women younger than 35 years who have migraine with aura (e.g., visual symptoms lasting less than 1 hour) have a risk of ischemic stroke of about 30 per 100,000 annually, which is twice the risk of those women who have migraine without aura. An IHS task force concluded that OCs may be contraindicated in women with migraine who have additional risk factors that cannot easily be controlled, including migraine with aura, because of a possible increase in the risk of ischemic stroke, and that these risks must be assessed and evaluated on an individual basis. Women with aura symptoms such as hemiparesis or aphasia or prolonged focal neurologic symptoms and signs lasting more than 1 hour should avoid starting low-estrogen OCs and should stop the medication if they are already taking it. Progestin-only OCs and the many other contraceptive options can be considered, as appropriate. Cigarette smoking should be strongly discouraged because female migraineurs who smoke one or more packs of cigarettes a day raise their risk of ischemic stroke by a factor of about 10.

Estrogen replacement therapy has a variable effect on migraine: 45% of patients show improvement, 46% show worsening of migraine, and 9% show no effect. If migraines increase when a patient starts estrogen replacement, the following strategies may be beneficial: 1. Reduce the estrogen dose.2. Change the estrogen type to one less likely to promote migraine. From most to least likely to promote migraine, these are, in order, conjugated estrogens (Premarin), pure estradiol (Estrace), synthetic estrogen (Estinyl), and pure estrogen (Ogen). 3. Convert from interrupted to continuous dosing in the case of estrogen-withdrawal migraine.4. Convert from oral to parenteral administration (e.g., a transdermal patch).5. Add androgens. Management of migraine during pregnancy and breast-feeding38 is beyond the scope of this chapter.

If you are having chronic headache or migraine for some time or feel it continueusly then it’s time to consult a reliable doctor. Dr. Randolph W. Evans is considered one of the best headache and migraine specialist in Houston, you may contact his office immediately for a consultation.

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