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Migraine Attacks Increase With Menopause, Study Finds

I just arrived in Los Angeles for the American Headache Society’s annual scientific meeting. It’s been a rough month, so I’m not sure how much of the conference I’ll get to attend, but I’m eager for whatever I’ll get to learn. Tons of research will be presented at the meeting, but one study in particular is more frightening than exciting:

A study of 3,606 women between the ages of 35 and 65 found that women who were in the transition to menopause or were already in menopause had more frequent migraine attacks than women who hadn’t begun menopause. In the study, about a third of the women hadn’t yet hit menopause (premenopausal), a third were in the transition to menopause (peri-menopausal) and a third had already entered menopause.

Only 8% of premenopausal women had 10 or more migraine attacks per month. Of women who were in the transition to menopause or already in menopause, 12% had 10 or more attacks a month. Researchers concluded that the peri-menopausal and menopausal women were 50% to 60% more likely to have frequent migraine attacks than pre-menopausal women.

Hormonal changes, particularly the drop in estrogen in peri-menopause and menopause, are thought to be responsible for this disparity.

I’d bet at least 99% of women have had a health care provider tell them to expect a decrease in their migraine frequency menopause. Many of us have even been told the migraine attacks will stop completely. This research raises serious doubts about the migraine nirvana we may have thought awaited us.

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Lower Risk of Breast Cancer for Women With Migraine

Finally, some good news for migraineurs. Women with migraine had a 30 percent lower risk of breast cancer than those without, according to a recently released study. Hormonal changes, which commonly trigger migraine, are a potential link.

In particular, migraine history appeared to reduce the risk of the most common subtypes of breast cancer: those that are estrogen-receptor and/or progesterone-receptor positive. Such tumors have estrogen and/or progesterone receptors, or docking sites, on the surface of their cells, which makes them more responsive to hormone-blocking drugs than tumors that lack such receptors.

The biological mechanism behind the association between migraines and breast cancer is not fully known, but Li and colleagues suspect that it has to do with fluctuations in levels of circulating hormones.

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Estrogen Withdrawal is a Migraine Trigger

The long-standing hypothesis that when estrogen levels drop right before and during a woman’s period, it triggers migraines has been supported in a recent study. The study also found a connection between increased estrogen levels and decreased migraine frequency. (It’s a Medscape article; go to BugMeNot for a password.)

In a second study, the same participants — all of whom had previously been diagnosed with menstrual migraine — had a reduction in migraine days when they received supplemental estrogen (via estradiol gel) before their periods.

Interestingly, if the supplemental estrogen was stopped too soon, the women’s estrogen withdrawal still happened, just later in their cycles. Researchers say that if the doses of supplemental estrogen were extended by a few days, withdrawal (thus migraines) could be avoided altogether.

These results appeared in the December 26 issue of Neurology; here’s the abstract. I got my information from the Medscape article, which I recommend reading — it’s one step closer to the source and less simplistic than my summary.

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A Headache Specialist’s Comments

Christina Peterson, a neurologist (and migraineur), is a blog reader who leaves terrific, educational comments. I always learn a lot from her. Some of her comments on recent posts are so informative that I want to be sure you all see them.

Warnings Proposed for OTC Painkillers

This is a really important post–it can’t be overstated.

In fact, the NYT article, if anything, understates the matter. The truth is that at this time, over 50% of all liver transplants are necessary because of the medical use of acetaminophen. It’s such a big problem that even the makers of Tylenol have run a commercial asking people not to exceed the recommended amount.

Gastritis and ulcers are no fun, and most people have been made aware of the cardiac and blood clot risks of anti-inflammatories like Vioxx and Celebrex, but a lot of people tend to think that ibuprofen and acetaminophen are benign.

They aren’t.

It’s also important to know that a lot of prescription analgesics, like Vicodin, Percocet, Fioricet, Amidrin (and all their generic names), also contain acetaminophen–so don’t double up.

If you are an intermittent migraine sufferer, and not a chronic headache sufferer, a double-blind randomized controlled trial has established that acetaminophen has no role in the treatment of acute migraine. There are better options available.

Men & Women Experience Pain Differently

This is vastly oversimplified. (Well, OK, it’s a newspaper…) But I trust this blog readership to be more sophisticated than the sixth grade level general readership a newspaper shoots for. So.

Most of the studies that have recently emerged have indeed shown a difference in pain processing between men and women. The major difference is that pain processing in women fluctuates with estrogen levels. (Estrogen–it’s our theme of the week, isn’t it? 🙂

Some of the studies available are simplistic and misleading–lab animals were injected with estrogen, and pain thresholds decreased, which led researchers to conclude that therefore, women were weak, and couldn’t tolerate pain as well as men. (Can anyone say, “Researcher bias”?)

But if you think this through, it is counter-intuitive. It makes no sense. Pregnant women have very high estrogen levels–estrogen levels climb throughout pregnancy, until they are very high by the time labor begins.

And menstrually-associated headaches occur when estrogen levels are at their lowest–the day before menstruation begins is the most common day for a menstrual migraine, and that is the day for a drop in estrogen.

Dr. Nancy E.J. Berman, who has done very important research on the effects of hormones on trigeminal neurons and the effects on orofacial pain, TMD, migraine and fibromyalgia, and who won the Wolff Award this year from the American Headache Society, also wrote the chapter on “Sex Hormones” in the book, The Headaches. She has noted that migraine improves both during pregnancy, when estrogen is high, and after menopause, when estrogen is low. She feels that this suggests that it is rapid changes in estrogen and progesterone that serve as a trigger for migraine attacks.

Some studies suggest that women tolerate pain better than men when estrogen levels are higher, and less well than men when estrogen levels drop–we are still discovering whether it is the rate of drop that is critical (likely), or whether it is also the estrogen:progesterone ratio that has an effect.

Other studies have shown that postmenopausal women process pain similarly to men.

I will say this, though: when I do Botox injections in the office, it’s generally not the women who get faint on me. 😉

Birth Control Pill News

This is all well and good…if you are young, and if you do not have migraine with aura.

Please refer to the following from the ACHE website: Will Using Oral Contraceptives Increase the Risk of Stroke?

It is the standard of care amongst headache experts to advise that women with migraine with aura either not use oral contraceptives at all, or use them very judiciously and with aspirin cardiac prophylaxis, and only if there are no significant cardiovascular risk factors. It is also recommended that women who have migraine without aura discontinue oral contraceptives after age 35. Smokers who have migraine should not use oral contraceptives at all.

I recall reading a recent article that surveyed migraine sufferers, and found that a significant proportion of primary care physicians were not aware of current recommendations regarding migraine and oral contraceptives. (I cannot, however, find the article in my giant stack-of-articles-to-be-filed. So, no citation for you–sorry. I think the author was Dr. Elizabeth Loder, but Google is not bringing it up.)

There is also newer data regarding the increased risk of heart disease in women with migraine, which was published in JAMA recently.

This study looked at women over 45, but estrogens, contained in the vast majority of contraceptives, are also a cardiac risk factor.

So–if you are going to proceed with this, be certain your physician knows you are a migraine sufferer (if you are), and research your family history and personal cardiovascular risk factors.

To learn more about and from Dr. Peterson, visit her websites, Migraine Survival and Headquarters Migraine Management.

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Migraine and Estrogen Officially Linked

A review of 643 unique journal articles related to estrogen and migraine establishes that the two are indeed linked. My initial reaction to this was “duh,” but stating the fact so plainly helps legitimize further clinical research on the topic.

The article concludes:

Epidemiological, pathophysiological, and clinical evidence link estrogen to migraine headaches. Triptans appear to provide acute relief and also may be useful for headache prevention. Clear, focused, and evidence-based treatment algorithms are needed to support primary care physicians, neurologists, and gynecologists in the treatment of this common condition.

In possibly related news, a study published in an oral surgery journal states that “the affective component of pain my be enhanced during the low-estrogen phase of the menstrual cycle in healthy women.” That is, women are more sensitive to pain from oral surgery when their estrogen is low. Perhaps the link isn’t only migraine-specific, but pain in general.

There’s tons of information available if you want to learn more about estrogen or menstruation and migraine. I recommend ACHE’s women and migraine section and their related newsletter articles (look under headache sufferer subgroups, then under women), and the National Women’s Health Information Center’s migraine section.