Dr. Sondra Altman, M.D., returned as guest speaker for the July 13, 1999 meeting of the East Bay Headache Support Group. Back in September 1996 she gave a lively presentation to the group about the role of hormones in triggering headaches in women, and she was invited back to tell us more about this fascinating subject, to which so many women headache sufferers can relate. There were approximately 37 people in the audience at this meeting, held in the Ball Auditorium at John Muir Medical Center, including a few men who came to support their wives/significant others.

Dr. Altman is a Walnut Creek gynecologist who is frequently asked to lecture to the lay community, and physicians’ and nurses’ groups throughout California, especially on the topics of menopause, perimenopause, and hormone replacement therapy.

Editor’s Note: As these notes were taken by a volunteer who is not a medical professional, and it was impossible to take down every word she said, they may not accurately portray the information she presented to the group. If you have questions about a possible link between the menstrual cycle and headaches, consult your personal physician.

What makes things very difficult for understanding moods and illnesses in women is that we're never the same one week from the next, Dr. Altman said. When new drugs were studied, until 1981 women were never included (the argument was they could get pregnant, or daily changes could confuse the study). It is true that medications are absorbed differently and utilized differently by the female body between the first half and second half of the menstrual cycle.

Describing the menstrual cycle in physicians’ terms, Dr. Altman explained that the period starts the cycle, it doesn't end it. During the first week both the estrogen level is low and there is no progesterone, and during the second week estrogen rises to a very high peak. Right before ovulation, say the day before, there is a very dramatic drop in estrogen. If the woman is ovulating and releases an egg, the cells around the egg become a little progesterone factory and they make progesterone. One of two things happens while she makes progesterone: "Either the peak drops and two weeks later you get a period, or nine months later you get a baby." (laughter) Once the woman ovulates, progesterone is released. It reaches a peak a week later (usually Day 21 of the 28-day cycle, or one week before her period). If the woman becomes pregnant, the progesterone keeps going; or drops if not pregnant. What progesterone does is cause us to have the same pattern of bleeding month after year after decade. Progesterone is in charge of bleeding control. When the amount of progesterone in the female body changes, the most obvious thing is the change in bleeding pattern. Estrogen dips and comes back up after ovulation and then there’s a second peak (not as high), and then drops again. It’s the withdrawal of hormones that makes us have a period.

Dr. Altman said that menstrual migraines are really not menstrual. Most women with menstrual headaches have the headaches not as they bleed, but before they bleed. There are a few women who get headaches on Days 3-5 of their bleeding, however. Those headaches are caused by the absolute bottom level of estrogen. There are women who have estrogen receptors from head to toe. It was discovered there are two different receptors: alpha and beta. There is something very real that goes on in the brain, in the central nervous system, that causes these headaches—neuro-transmitters are affected by estrogen. The whole configuration of brain cells is different in the presence of estrogen and the absence of estrogen.

Some women have headaches triggered by the bottom level. Whatever that point is, it’s below the threshold of what their brain needs to not have a headache. But most women who suffer from monthly headaches get their headache two to three days before their period starts. And it seems it is the rate of fall of the estrogen level that triggers the headache. She went on to say, "But that can't be all that it is, because many women get headaches here while others get it here." (Dr. Altman pointed to a chart she brought to explain hormone levels.)

One woman asked, "Why do I get a headache two weeks before my period?" And Dr. Altman answered, "The same phenomenon happens. There has to be something that goes on when our estrogen level drops in the presence of progesterone."

For a lot of things in the brain, progesterone does the opposite of what estrogen does. Progesterone is a sedative, like valium. Estrogen has many antidepressive effects. So there’s something chemically that is going on when estrogen levels drop and progesterone levels rise that exacerbates in a negative way.

Dr. Altman said that first of all, menstrual migraine is a misnomer—they are really pre-menstrual. That headache is different from the water retention headache that the PMS salt cravers have. It is said that two-thirds of women experience some level of PMS, but it is hard to study. When you’re a subject in a study you can't have anything else going on in your life. But that's not the real world.

Dr. Altman developed listening skills when seeing her patients, and learned to ask questions. She has discovered that women who are salt cravers, have tension headache, retain water, are irritable, probably would want to kill someone; are most likely having something go wrong with their progesterone, because it makes you irritable. Then there are women who are doing a sneak preview of menopause—they’re chocolate craving, tired, clumsy, and everybody hates you—so you want to kill yourself.

The weepy, sad, crying, chocolate person is more likely to also have a pre-menstrual problem. A hormonal imbalance is when the body has too much estrogen and too low progesterone, or vice versa. If a rapid drop of estrogen is experienced, then a hormonal migraine can ensue. Dr. Altman has discovered that if a migraine is triggered by a rapid drop of estrogen, replacement estrogen can be taken sublingually (melt it under the tongue) and twenty minutes later the migraine could improve. This is the woman who experiences a rapid drop of estrogen, and taking the small dose of estrogen keeps her estrogen level from falling as rapidly. If one wants to use estrogen on an as-needed basis, she suggests estradiol (Estrace), which gets into your blood level in fifteen to twenty minutes if taken sublingually. If your cycle is regular, the worst case scenario is that you will take some estrogen you don’t need. It’s a tiny amount. That amount will add 25-50 mg of estrogen—not a lot, but it seems to be enough to brake the rapid drop and prevent headache. She said, "If you get a headache always three days before your period, and you have a 28-day cycle, take a small dose of estrogen sublingually every day starting Day 24. And take it one day past when the headaches usually last. If the headaches occur mid-cycle, chart when it happens (36-hours)." Dr. Altman has found this therapy works very well for a lot of women. And she said, "Then you’re only taking your Maxalt (or other headache medication) when you need it." She suggested you always have some extra estrogen in your purse, at least until your cycle changes, usually in the late 40’s. Dr. Altman also stressed that, for women taking HRT (hormone replacement therapy), using a patch is better than taking oral estrogen.

Another trick to get rid of hormone level fluctuation is to take birth control pills. She drew a picture of a pill pack, showing three weeks of hormone and one week of placebo. Dr. Altman said, "Women don't get migraines when they're on the Pill, they get it when they go off—when they're taking the sugar pill during the fourth week." This occurs usually the third or fourth day of placebo week. What if you want not to get a headache? The newest birth control pill coming out has estrogen every day. If you’re taking one with a placebo week, just keep going with estrogen during the fourth week. Dr. Altman said that night sweats and hot flashes occur during placebo week. She suggested that any woman over the age of forty on the Pill take either an estrogen tablet every day or a patch in place of that sugar pill. Even two days of sugar pills gave her a migraine. She said that you don't need a period when you're on the Pill. When the birth control pill was first created, it was set up so a woman would have a period every month, just because having a period meant you weren’t pregnant.

She said again, "You do not need a period when you’re on the Pill. Having a period just shows you're not pregnant." Every day your body gets a little estrogen and a little progesterone with the Pill. Light periods are the result of taking both estrogen and progesterone at the same time. It’s balanced, so the period is light.

Dr. Altman said, "The new thing in medicine is, if somebody didn’t do a double-blind study on something, it probably wouldn't happen. Until Newton proved there was gravity, there wasn't." What happens during those seven days without estrogen is that you experience a drop in estrogen. The only limiting factor is if you start to get breakthrough bleeding. She stressed that a woman should never, never let her brain go without estrogen. You don't have to have a migraine if you add estrogen on low-estrogen days. She said that the people who make Amerge, a longer-acting variant of Imitrex, recommend starting Amerge before the expected migraine, but Dr. Altman contends that if the cause is a drop in estrogen, it is better to just add estrogen and then you won’t have to take the Amerge at all. You have to continue to support the level of estrogen until the pill gets back to giving estrogen, or your body creates enough estrogen on its own.

She mentioned taking low doses of an anti-depressant called Lopressor. This can be used to treat hot flashes in women who are menopausal but have breast cancer so they can't take estrogen. The amount of estrogen for supplementing the cycle is a drop in the bucket. The threshold for preventing a period is a lot lower estrogen than the threshold for preventing a headache.

What happens when you get to menopause? For some women, the headaches finally go away. No estrogen to drop, so no headaches. One of the hallmarks of getting to menopause is that your hormone levels are very chaotic…often it’s worse before it's better. This may be a good time to take birth control pills. Or you can take estrogen every day.

Dr. Altman on hormone replacement therapy (HRT): Patches work much better. Unless you break out in welts from every patch there is, you should use a patch. The reason is: Oral medication will peak two hours after you take it, and then drop…and then peak and then drop. Those who get migraines don’t react well to that. You can divide an oral dose and take it twice to get a more even level of estrogen. Patches are changed twice a week, and it’s level dosing, so you never drop. She said two tricks to take migraine headaches out of HRT is patches and no breaks—never, never, never go without estrogen.

Dr. Altman said the gynecologists in Walnut Creek managed to get all of Rossmoor to have their periods all on the same day with HRT. It was a phenomenal accomplishment.

(laughter) You had estrogen for two weeks, you ovulated, then progesterone, then a period. But now both estrogen and progesterone are given everyday, or estrogen every day and two weeks of progesterone. She stated that every body is different. You will need to try different methods of HRT to find the one that works best for you.

Dr. Altman concluded her presentation and welcomed questions from the audience.

One woman asked about the Estraderm patch for HRT, and Dr. Altman said that Estraderm is an old product—it is time to upgrade. She recommended trying the Vivelle patch, as the absorption is much better. Very recently they came out with the Vivelle Dot which is fifty percent smaller than before. It is the size of a postage stamp. The adhesive is better and the absorption is better.

Dr. Altman was asked if she took new patients, and she answered that her practice is closed with the exception of new breast cancer patients who are struggling with hormones. She will see people for a consultation, but that’s all.

Someone asked Dr. Altman about Premarin, a popular source of estrogen for HRT, and she answered, "For reasons I don't understand, Premarin is a terrible form of hormone replacement for women who have migraines. It cause more water retention than other forms of estrogen…" She went on to say that there is a product called Estrace which is pure natural estradiol, as the patches are. This estradiol is identical to what the ovaries make. Everything is natural except for Premarin and birth control pills. Premarin is pregnant mare urine, so there might be some other steroids, etc. in it that are not good. It’s almost like a prednisone phenomenon. She stated that Premarin is a bad choice, we have a lot of other estrogens now. Estrace is a pure product—it has one thing in it.

Some women with migraines may be better with Premarin than with nothing, but for a long time, all we had was Premarin, since WWII. All the other stuff has been around the last ten to fifteen years. If you want longevity data, though, then you want Premarin. She said Premarin is one of the few old drugs still in use, but there are other, better choices now available.

A woman in the audience asked, "Is estrogen treatment effective for me who gets migraine the second day after my period starts?" Dr. Altman answered, "Yes."

Asked if there was a birth control pill she’d recommend, Dr. Altman answered, Mircette. It’s the lowest dose range, which is more appropriate as a woman is moving towards menopause. She said that birth control pills now have much less hormone in them. When she first started practicing gynecology, they were 50 micrograms, then 35 mcg, then 20, and soon they’ll be 10. The 10 mcg pill will be called Femhrt and they’re not birth control pills, but are for women who need to start hormone replacement therapy.

Dr. Altman was asked, "For women on birth control, is there a pill with 28 days of estrogen and no placebo?" She answered that we don’t have one yet, but there will be one.

Dr. Altman talked about the price of adding estrogen. She said that usually your insurance company will pay for three packs of birth control pills for three months, but if you find it helps your migraines to take estrogen continuously, then it’s four packs for three months. Will insurance companies pay? Well, if they won’t, it's much cheaper to buy $35 packs of the Pill versus $120 for nine Imitrex pills. She told us to not do only what the insurance company says. "If what they allow isn’t a good fit for you, then buy your own estrogen. This is not terribly expensive stuff," she said.

The question was asked, "Why does progesterone give me a migraine?" And Dr. Altman answered that it somehow turns down something good that estrogen does for the brain. Good things in brain—estrogen turns those off, and progesterone turns them down. Sometimes you need to add more estrogen, and sometimes you need a different progesterone. It depends on what progesterone you use—some are milder. Provera is available in 5 mg and 2.5 mg…but it causes a lot of water retention. We now have a natural, commercially-available progesterone called Prometria that is identical to the progesterone our ovaries make. It was new in 1980. Its main side effect is caused by the peanut oil included in the pill. If you’re allergic to peanuts, don’t take it. It also makes you sleepy, so take it at bedtime. Prometria is the only progesterone that is FDA-approved for HRT. Provera never bothered to get FDA approval— they didn’t need to as they had a monopoly.

Another thing that is off-label is progesterone vaginal cream, called Crinone. It first came out as a nine percent concentration, and was for women who had test tube babies. Since these women didn’t ovulate every month, they didn't have enough progesterone to sustain a pregnancy. They would get daily shots of this throughout pregnancy. It's pure enough and effective, so Crinone received FDA approval for menopause. It is used in a four percent cream for hormone replacement, every other month. It is effective to shed lining tissue, and little gets into circulation. Dr. Altman said it was her back-up when all else has failed.

She stated that there are always different choices available. There is a patch now that has an estrogen/progesterone combination. And there is no one size anymore. She said, "It's like shoe shopping…shop until you're happy."

Hormones affect antidepressants. There are three mechanisms of anti-depressants. She mentioned elavil receptors, amino inhibitors, and serotonin. Estrogen in a variety of ways will enhance serotonin levels. For women in their forties and fifties in depression, if they are not responding to antidepressants, we need to check estrogen level.

Hormones enhance the effectiveness of the antidepressant. Dr. Altman said she would be worried if someone was taking high doses of natural progesterone and also taking a (unintelligible) agent.

Dr. Altman was asked about testing hormone levels. She said that endocrinologists do very well with hormones that stay the same, but they can't handle change. They want you to take a hormone test, but don't tell you when. Since hormone levels are different every day, it can really skew the test. She added that measuring hormone levels (specifically fsh) has fallen out of favor, because there's just such a fluctuation. So now doctors are just trying to treat the symptoms.

There is only thing that can make menopause happen earlier, and that is smoking, according to Dr. Altman. It doesn't matter if you have one ovary or two, or if you took birth control pills for twenty years. She also said, "When you're trying to get pregnant, you don't get to play with hormone drugs."

One concerned mother spoke about her fourteen-year-old daughter experiencing migraines. The mother was inquiring about putting her on birth control pills, but she was told by someone that migraines would give her an increased risk for stroke, and that birth control pills could cause stroke. Dr. Altman answered, "That is very old information that has to do with the 50 microgram pills. There is no increase in risk of stroke. She recommended that the daughter use very low dose pills. And suggest, "If you want to know if hormone fluctuations contribute to your daughter’s headaches, try the hormones as a trial.

Elavil and estrogen were mentioned by someone in the audience. She tried taking Elavil but became super depressed and had more headaches. Dr. Altman said that Elavil has lots of side effects (constipation, urinary retention, dry mouth) and estrogen doesn't. When in an extreme situation (missing work or school because of headaches), like the teenage girl previously mentioned, she suggested that six weeks of continuous estrogen be given. The worst it can do is cause spotting.

Dr. Altman asked about the dosage of estrogen, and said that when you reach menopause and you're on HRT, .625 estrogen is a good dose. She went on to list the benefits of hormone replacement therapy. She said that the symptoms of menopause (hot flashes, night sweats, vaginal dryness, etc) last longer the younger you start. Estrogen protects bones (i.e. bone density), and Dr. Altman mentioned a new estrogen patch, called Estrotab. Estrogen offers cardiac protection, at least between the ages of fifty and seventy you get coronary artery protection when taking HRT. It will help to keep your bladded and vagina from getting dryer and more susceptible to infection. She stated that once a woman goes through her change, she needs to figure out her longterm needs.

She said that ten percent of women stop their periods (i.e., go through menopause) and never notice it. But the other ninety percent of us experience good months, bad months, lose your mind months…

Someone in the audience asked Dr. Altman about supplements with soy to help menopausal symptoms. For hot flashes there is some data. But Dr. Altman suggested that we go to Chinatown and look around. What is the posture of the older Asian women? She said that Asian women have worse bone density than Caucasian women. Phytoestrogen helps for hot flashes, but that's all they do. They're a good source of protein, though, so it certainly isn't bad for you.

One women said, "When I'm taking progesterone, menopause symptoms come back." And Dr. Altman answered, "Progesterone turns down the effect of estrogen, so add extra estrogen during those days."

She encourages women to use natural hormones, as it also may increase your good cholesterol (HDL). She also mentioned that natural progesterone allows a woman with a uterus to get the benefit of cardiac protection.

Dr. Altman stated that changing testosterone levels in women doesn't help headaches. Testosterone is turned into estrogen in both a man’s and a woman’s body. There may be something that when a man's testosterone level drops, their estrogen level drops also.

She said that women develop Alzheimer’s Disease more often than men possibly because women have more testosterone as they get older.