SEPTEMBER 11, 2001 MEETING
TOPIC:  “HORMONES AND HEADACHE”

Though September 11, 2001 was a very tragic, emotional day for our nation, and the whole world, the East Bay Headache Support Group decided to hold its support group meeting as planned that evening.  Our speaker was Dr. Sondra Altman, a Walnut Creek gynecologist.  Dr. Altman gave presentations to our group twice before (September 1996 and July 1999), with large attendance numbers; but, because of the events of that day, attendance was only 19.  Everyone agreed it was beneficial to listen to Dr. Altman’s message on female hormones and their relationship to headaches, and take a break from listening to the news stories of the tragedy in New York, Washington DC, and Pennsylvania.

Over the past 12 years Dr. Altman’s Walnut Creek private practice has evolved into a specialty of menopause, hormones and the problems they create.  And she personally suffers from menstrual migraines, which gives her an added perspective on this common problem for women. 

Dr. Altman began her presentation with the statement that to understand women and headache you need to look at women and hormones.  Twenty-five percent of women will have headaches during their reproductive years, and 75 percent of women with migraines have menstrually-related migraines.

There are three times in a woman’s life where headaches are most likely, all times of great fluctuation of hormones:

1.)  At puberty.

2.)  Taking birth control pills.

3.)  During the menopausal years.

She said that the level of hormones in a woman’s body is not the same two days in a row.  They constantly fluctuate.  When there is a drop in estrogen there is a drop in nitric oxides, which causes instability of the blood vessel, and spasms.  When the estrogen level drops, a migraine can be triggered.  This is usually 2 to 3 days before the onset of the menstrual period, when the drop in estrogen is rapid.  She added that some women also have migraines triggered during the milder estrogen drop for ovulation, in the middle of the menstrual cycle.

The job of progesterone is for bleeding control.  Something goes on so estrogen dropping in the presence of progesterone (during the 2nd half of the cyle) more likely triggers migraine.

Estradiol is the real stuff the female body makes, the natural estrogen hormone.  And progesterone is the hormone that brings on the bleeding of the menstrual cycle, or sloughing off of the built-up lining of the uterus.

Estradiol is sold under the name estrace or estradiol and can be obtained from a pharmacy with a doctor’s prescription.  It can be taken sublingually, or under the tongue.  Dr. Altman said that 20 minutes later the instability of the blood vessel is gone and possibly the headache…that is, if your headache is triggered by a drop in estrogen.

Dr. Altman said, “So, the best thing is…don’t let your estrogen drop.”

She went on to talk about birth control pills.  They come in packs of 28 pills (4 weeks of daily pills).  This number 28 was not made for women’s physiology—it was just made up because 28 is a number divisible by 4.  Dr. Altman asked the audience, “Why is the pill started on Sunday?”  And then gave us the answer with a chuckle, “So you get your period during the middle of the week so on the weekends you can keep your husband happy.”

When a woman is on birth control pills, the period is scanty.  Typically, the woman takes three weeks of estrogen and 3 days progesterone.  Dr. Altman drew a diagram of a menstrual cycle for a woman on the Pill:

During the 1st and 2nd weeks the level of estrogen is at it’s highest.  Then during the 3rd week the estrogen level begins to drop and some women get a headache at this time—brought on by the estrogen drop.  But during the 4th week when the women only take a placebo (no estrogen) is the worst week for headache.

Dr. Altman made the statement that the birth control pill is artificial—bad.  Mutations can happen during ovulation where abnornal cell division can develop into cancer of the lining of the uterus and ovarian cancer.

Seasonale is a new birth control pill on the market, which features an extended cycle of 84 days (9 weeks of birth control pills and 5 day break).  Dr. Altman said a menstruating woman can’t go more than 8 to 9 weeks without some spotting.  The estrogen and progesterone in this pill cancel each other out.  Ultimately, in all birth control pills progesterone is dominant.  So stop the 5-day break.  Take estrogen during this week, either orally or wearing the lowest level patch (.025 ml).

 Dr. Altman mentioned Dr. John Arpels, a well-known gynecologist in San Francisco who specializes in menopause.  (Editor’s Note:  Dr. Arpels spoke to the East Bay Headache Support Group in March 1998, and notes of that meeting are available in hard copy at our meetings, or on our Web site.)

In a birth control pill, 20 micrograms estrogen is the lowest you can get, whereas in HRT (hormone replacement therapy), the estrogen can be as much as 1.25 micrograms.  HRT for menopausal women has much more estrogen than birth control pills:  .02 micrograms vs 1.25 mg.  It is measured in different units so you can’t make the comparison.

Dr. Altman suggested that women who are on the Pill and experience migraine headaches during their placebo week should supplement with estrogen during that week.

Dr. Stein, medical advisor for the East Bay Headache Support Group, spoke from the audience and made the comment:  “With the extended cycle, women will think periods will be heavier.  This is not true because the estrogen is balanced out by the progesterone.  But, if a woman has a problem with uterine fibroids, there may be a different problem.”

Dr. Altman said she began taking estrace herself sublingually (under the tongue) because she got headaches when she forgot to take her birth control pill.  The question was asked, “Can you get rebound headaches from this?”  And Dr. Altman answered, “Yes, if estrogen is taken sublingually it goes up quickly and then drops quickly.  So, do rescue medication—swallow an estrogen pill (slower delivery of estrogen to the body), or use an estrogen patch.”

Dr. Altman talked about Estrace and Gynediol.  She said that Estrace wears out in 24 hours and that gynediol is very predictable.  The patch takes 12 hours for the estrogen to take effect.  She said, “Next time, preempt it—don’t even let it drop.”

Dr. Altman said that as a woman gets into her 40’s, she develops unreliable ovaries.  This is evidenced by hot flashes or the feeling of not being able to concentrate.  It used to be that women were told by their doctors that they could not start taking hormone replace-ment therapy until their periods had stopped for 6 months (when the menopausal symptoms are at their worst).  But now women in their 40’s who are experiencing the “decade of declining ovaries,” can get HRT to alleviate the hot flashes, dryness, and other symptoms of declining estrogen.

Doctors have tested women’s FSH hormone levels and stated “If the results are above 40, it’s menopause, and if below 40, it’s not.”  But Dr. Altman said this is not true and that it all gets worse when you’re in your 40’s.  She said that all women have a set point of estrogen at which above they feel great, and below they feel lousy.

For HRT, she recommends using the estrogen patch over taking estrogen orally.  It provides a low dose all month long.  The lowest patch gives about 35 mg and keeps you from going way too low.

An audience member asked, “When I stop taking the Pill (placebo week), I get cramping.  Is it estrogen or progesterone?”  And Dr. Altman answered, “Neither, it’s prostaglandin.”    Dr. Altman added that birth control pills make women have cramps, but HRT does not.

Pill sizes for estradiol for use in HRT:  20 micrograms, 30 micrograms, or 50 micrograms.

Dr. Altman made the statement, “After menopause, either your headaches will go completely away, or you’ll have them all the time.”  Again, we need to stabilize the hormone level to keep from having headaches (at least hormonally-related headaches).  Dr. Altman said when she sees a menopausal woman with migraine, she always recommends starting with the patch for estrogen delivery.  If a woman takes estrogen orally in the morning, then she might wake up with a headache the next morning, because the estrogen pill lasts 20 hours.  Dr. Altman drew a diagram of estrogen delivery if taken orally, where there is a sharp peak and then drop-off, and also delivery by a patch.  The estrogen delivery from the patch is a gradual curve, with no steep drop-off.

For those of us with Internet access, Dr. Altman suggested we go “drugstore.com” to comparison shop prices of the various hormones available by prescription.  She said that Premarin, a common estrogen pill, will cost the consumer about $30 per month, whereas Synaptin is only $15.35 per month.  Also there is Synestrin, a delayed release estrogen pill.

Premarin is made from pregnant mare’s urine and is an impure product.  20% of the molecular weight is still unknown, and it can vary a lot from batch to batch.  Premarin also is known to cause water retention.  “It’s been around for 40 years…but now we’ve got better stuff,” said Dr. Altman.

She recommends that you not take that 5-day break if you’re a woman who is a migraineur and on HRT.

Provera (a progesterone) is a vaso-constrictor and can cause problems for migraineurs.

There is a micronized progesterone—now available as Prometrium which costs about $18 per month.  “It tends to make you sleepy, so take it at night,” advised Dr. Altman.  The generic is $10 or brand name is $15 per month.

The estrogen patch is better, according to Dr. Altman, as delivery of the hormone is very stable.  Various patches on the market now are Climara (applied once per week), and Vivelle, Alora and Estrin (applied twice per week).

Dr. Altman said there is no downside to taking estrogen short term.  You have to get through the change (menopause), and until you get to a flat line (takes 2 to 7 years).

Hormones tend to trigger headaches mostly during the times of transition in a woman’s life—during puberty and menopause—and the rest of the time it’s usually better.

When taking estrogen it is important to also take progesterone to protect the lining of the uterus.  Typically a woman on HRT is advised to take estrogen on Days 1 to 25, and then take a break for 5 days.  And progesterone is taken on Days 16 to 25.  Dr. Altman commented on the nicknames for these 2 hormones:  Estrogen is called the “brain happy hormone,” and progesterone is a “pain in the butt.”

Estrogen increases the level of estrogen receptors and how sensitive they are…and progesterone does the opposite (decreases level of estrogen receptors).

Progesterones are vasoconstrictors (constrict blood vessels).  She said that this can cause sexual problems, as constricted vessels can’t engorge.

Progesterone cream is available from your pharmacist.  It helps to control hot flashes and flushes and mood, but doesn’t help a woman retain bone density, one of the problems of reduced estrogen production.

A menstruating woman actually has only one good week each month—the first week after her period—as that’s when the body makes enough estrogen for things to run smoothly.

Dr. Altman told us about a combo patch:  the combi-patch delivers both estrogen and progesterone transdermally (through the skin) together.

After a woman on HRT goes through the crazy making days of menopause, she should use the lowest amount of estrogen and progesterone needed to make her feel sane.

Kaiser San Francisco did a study on the proposed 100-day cycle and a 6-month menstrual cycle.  This is where a woman takes hormones so that her period only comes once every 100 days, or once every 6 months.  But final results of the study are not in yet.

Dr. Altman said that once a woman has her uterus removed, then she does not need progesterone (this means she can safely take unopposed estrogen). 

She suggested to the women in the audience that if they are still cycling, each should create a map of her menstrual cycles and figure out when her headaches occur.  She told us to be Nancy Drew investigators.  Then, if we determine if any of our headaches are triggered by hormones, we can make adjustments in our hormone levels (supplementing with low doses of estrogen when we experience a drop in estrogen).

A woman in the audience said that she takes both estrogen and progesterone every day, and Dr. Altman told her that it’s OK to take estrogen alone for a month or 2.  She said to check them out individually.

Dr. Altman said she has known some women whose migraines went away after they had hysterectomies.  But for others, the migraines stayed the same or even got worse.

The question was asked, “What is the state of the art in HRT?”  Dr. Altman answered that it is best to take progesterone every day, along with estrogen.  But with progesterone you will experience the symptoms of PMS.  Now there is a pill available to treat PMS symptoms, called Serafem.  There is also a condition called PMED, or Premenstrual Euphoric Disorder.

Dr. Altman said that she prescribes both Prozac and Serafem together, for the woman suffering with PMS symptoms and depression.  The medications are taken together for 10 to 12 days each month to reduce symptoms.

She said as you need a higher dose of estrogen, you need to take a higher dose of progesterone.  If taking .625 mg of Premarin, one can get by with having a period only every 3 months.

Dr. Altman gave a rapid overview of the different hormone delivery systems, and mentioned the following:

        Cenestin (delayed release)

        Estrace and Gynodiol (forms of estradiol, or natural estrogen)

        Prometrium (progesterone)

        Climara patch (applied once per week, very thin and unobtrusive)

        Vivelle dot (applied twice per week, very small patch)

        Alora (applied twice per week, and the most transparent patch)

        Esclim (the most hypoallergenic patch, and easy to cut down to the size required — like a bandaid.

 She said a woman can use a 3-day patch as a rescue—when she needs a little extra estrogen over a few days.

 Dr. Altman said that 75% of women with migraines have identified hormones as being one of their headache triggers.

She said there are 2 estrogen receptors:  alpha and beta.  And different formulations of estrogen have different affinities for receptors.  The lining of the uterus, and the brain, have both.

When supplementing with estrogen, always start with low doses and then gradually increase only as needed.  She encouraged the audience saying there is no reason not to try adding estrogen on those estrogen-drop days in our cycles.

Lower levels of estrogen also make sleep worse.  She made the statement that the only women who are awake at night are “perimenopausal and menopausal women and nursing mothers.”

The intention of the East Bay Headache Support Group is to provide information and resources.  It does not provide medical advice, which should be obtained directly from a physician.  Meeting notes do not necessarily reflect an accurate representation of the speaker’s presentation—they were taken by a lay person.