Can Hormonal Changes In 60 Year Old Females Causes Changes With Migraines

April 27, 2018

6 min read

Managing migraine in women often ways managing hormones

Source/Disclosures

Published past:

Disclosures: Pavlovic reports no relevant financial disclosures.

Prevalence of migraine among women is about three times that of men, and fluctuations in female sex hormones often play a role in the onset of the condition. Women are peculiarly vulnerable to migraine during the childbearing years, which are also by and large the almost agile and demanding years of a adult female'south life.

"The evolution of migraine in women is related to big hormonal times of change. It picks up at menarche and rapidly increases in incidence and prevalence during the teens, 20s and going into the 30s and 40s," Jelena Pavlovic , Doc, PhD, of the Montefiore Medical Middle at Albert Einstein College of Medicine, told Endocrine Today. "In terms of burden, information technology culminates in the reproductive years, when women need to be the most productive, with young children and jobs."

Pavlovic talked to Endocrine Today nigh the mechanisms of hormonal migraine, how the condition is diagnosed, and the different treatments that may benefit patients with these debilitating headaches.

What types of hormonal changes are nearly likely to cause migraine?

Pavlovic: Hormones bear on migraine in women on ii different time scales. Migraine is a disorder that manifests around menarche and is nigh common in the 30s and 40s. The monthly frequency of migraine will worsen during perimenopausal changes; over again, it is a time of dramatic hormonal fluctuation. Postmenopausally, migraines generally meliorate. They are less frequent and sometimes disappear completely.

The other time calibration is the monthly time scale. This involves the hormonal change that happens within a month in the menstrual cycle. These attacks tend to cluster and will occur nearly frequently around perimenstrual hormonal changes. About threescore% to 70% of women are thought to have perimenstrual attacks. The International Classification of Headache Disorders has given these the name "menstrually related migraine." There are two categories of these. In pure menstrual migraine, which affects a very small percentage of women, about v% to 10%, the woman has attacks exclusively around her flow. The window is nigh 5 days around the onset of bleeding, and mostly starts about 2 days prior to the onset of bleeding.

The other diagnosis is menstrually related migraine in which the attacks occur in the 5-day window during menses only tin can also occur at other times. The diagnosis is mutual and affects 40% to 70% of women with migraine. This is very gratifying to care for because nosotros tin offering these patients medication they can take for a limited menstruum of fourth dimension. Almost young women are hesitant to introduce a daily medication, just it is very easy to convince someone to take a medication every solar day on just those days, especially if the patient clearly recognizes that she is quite disabled during that time. It is such a pocket-sized intervention, it is for a express time, and it makes them feel much better. It's nice to practice medicine that mode.

The catch to this is that menstrually related migraine is often not recognized by those who do non specifically practice in that area of medicine. If you ask women if their migraines occur with their periods, they often may not recognize this because the headache will typically offset virtually 2 to 3 days before the onset of bleeding. The patient might not perceive that as being associated with her period.

Migraine in general is under-recognized in clinicians' offices and is commonly under-diagnosed. When clinical studies are done, almost anyone who actually has a diagnosis of migraine certainly does accept migraine because information technology's more difficult to get this diagnosis in full general medical offices than information technology should be. The upshot in many studies becomes that people may say they do not have a history of migraine, but they have frequent headaches that are migraines.

How exactly do hormones bear upon migraine? Which hormones are involved?

Pavlovic: What we typically consider to exist the trigger of perimenstrual migraine attacks is withdrawal of estrogen, which is really the decrease in estrogen in the tardily luteal phase of the menstrual cycle prior to the onset of haemorrhage. That decrease in estrogen has been observed to precipitate a headache occurrence in those women who do have a history of migraine. It takes a sensitive key nervous system, such as that in a migraine sufferer. Nosotros presume that this is genetically predetermined in a very polygenetic, complex way.

Although the field is primarily focused on estrogen withdrawal, this may happen with progesterone decreases also. This is a subject of enquiry, particularly my current research. For example, my work at the Study of Women's Health Across the Nation (SWAN) has included a particular study of the ovulatory cycle (Pavlovic JM, et al. Neurology. 2016;doi:x.1212/WNL.0000000000002798). This involved women who were in their commencement or 2d year of recruitment while still having ovulatory cycles; basically, women in their 40s with ovulatory cycles. Nosotros compared the women with migraine to controls. We were not looking at headache, we were simply looking at the blueprint of their hormonal change during the late luteal stage, from the estrogen top to drop prior to bleeding over 5 days. We saw that there was a faster charge per unit of refuse within women with migraine, merely it was stage specific. It was late luteal phase, and information technology was twenty-four hour period specific. With the offset 2 days from summit, the rate of estrogen drop was faster in women with migraine than in controls.

From there, we came up with this two-striking hypothesis of migraine triggering effectually flow, because if you interview women with migraine, it doesn't occur with every menstruation. Even the diagnostic criteria state that the headaches should occur in at least two of the final three menstrual cycles. Women will not have a reliable menstrual migraine assault with every catamenia. Besides, during ovulation, there is a decrease in estrogen that is commonly big, even in absolute value. The magnitude of it is greater than the magnitude of the late luteal drop. And then, if it were only estrogen withdrawal, if estrogen was the only mechanism, why wouldn't the migraines occur at other times of estrogen decrease, such every bit ovulation? The study we did in SWAN suggests that there is a faster rate of decline merely in women with migraine and only in the tardily luteal phase, not in the periovulatory phase.

This suggests that we demand another trigger to come forth and tip an already sensitive system over into migraine.

How should hormone-related migraine exist treated during the different phases of a woman's reproductive life?

Pavlovic: The perimenstrual migraines are specifically treated with something called mini-prophylaxis, or mini-prevention therapy. In full general, for migraine treatment, patients who have 1 to two migraine attacks per month can have a medication such as Aleve or Advil, NSAIDs or triptans. If these medications work well enough, that's information technology for those patients. For those who take more than than nigh 4 to five headache attacks per month, we will suggest preventive treatment, which is a daily preventive medication. These might be antidepressants, anticonvulsants or beta-blockers, such as propranolol and nadolol.

Women with premenstrual migraine, fifty-fifty if they take migraine at other times, will be offered mini-prophylaxis during those days, especially if their periods are regular and predictable. Patients are brash to go along a headache diary. A physician can then study the headache diary and identify a clear window of perimenstrual attacks and advise accordingly. Through this mini-preventive treatment, the patient takes daily medication prior to the onset of the assault, but only for these 5 to 7 days. This can be done either with NSAIDs, such as Naprosyn 550 mg twice daily, or with a triptan, such as naratriptan. We like longer-lasting medications, so we tin can offer coverage for well-nigh of the 24-hour interval. Naratriptan is i of the longest-acting triptans. If the patient's period is due to go far on Sabbatum and the headache typically starts on Thursday morning, she tin can accept the first pill on Midweek night at bedtime and proceed that for 5 to 7 days.

Some other option is to bridge the estrogen drop with something similar a transcutaneous estrogen patch. Lastly, patients can opt to use a 3-month contraception, such every bit Depo-Provera. One consequence with hormonal treatment is that although information technology works very well for a lot of women, it can really worsen headaches in others. This is always the risk, and we don't take a diagnostic screen for this.

Also, the women who typically come to usa are ordinarily already in a pickle — the classic is a 24-yr-quondam graduate student who is studying and needs something to get her through information technology. They come up in when they're having difficulty, and they don't desire to take a risk at that time that it may worsen their headache.

An additional caveat is that estrogen-containing compounds are contraindicated in women who have migraine. There is an absolute contraindication in the WHO and American College of Obstetricians and Gynecologists guidelines. Information technology's been suggested that this is probably dose-dependent. The American Headache Society recommends that this should probably be decided on a case-past-instance basis. However, these situations are challenging. At that place is a perception, both by practitioners and patients, that hormones are contraindicated or somehow dangerous in migraine, which is untrue. They are generally very safe, with a few caveats. Yet, this perception adds an extra layer of hurdles for a woman with migraine to actually obtain hormonal handling.

Are there whatever other approaches to alleviating hormonal migraine?

Pavlovic: There is increasing evidence that we demand multimodality treatments, such equally behavioral intervention similar biofeedback, cognitive behavioral therapy, relaxation and so on. A lot of non-headache neurologists are under the impression that you just requite the patient an effective drug and it's stock-still. This is truly a heed and encephalon disorder. Although women may exist started on appropriate medication therapy, they may also benefit from an integrated approach that includes practice, relaxation and biofeedback.

Also, new therapies are on the horizon. CGRP antibodies that inhibit calcitonin factor-related peptide are making their way through the FDA and are expected to be on the market in 2019. Neuromodulation therapies, such as vagal nervus stimulation and transcranial stimulation, are as well recently emerging treatments for this population. – by Jennifer Byrne

For more information:

Jelena Pavlovic, Doctor, PhD , tin be reached at 1250 Waters Place, Bronx, NY 10461-2720; email: jpavlovi@montefiore.org.

Disclosure: Pavlovic reports no relevant financial disclosures.