MARCH 2002 MEETING

TOPIC:   “THE ROLE OF HORMONES AS HEADACHE TRIGGER”  - Dr. Angelyn Thomas, OBGYN

The female sex has long been linked to migraine, and it’s well-known that women in their reproductive years experience many more migraine headaches then men of similar age.  The East Bay Headache Support Group was pleased to have Dr. Angelyn Thomas, an Oakland gynecologist, as speaker for the March 12, 2002 meeting.  The meeting was held in the Ball Auditorium at John Muir Medical Center, with 35 in attendance.

Dr. Thomas began her presentation by talking about the roles hormones play in the different stages of a female’s life. 

Menstrual Cycle

The menstrual cycle consists of a follicular phase during the first two weeks.  This is when the brain stimulates the ovaries to ovulate, and is an estrogen-dominant phase.  Then during the luteal phase progesterone is dominant.  What happens in the middle of the cycle?  Dr. Thomas explained that the estrogen level drops during ovulation and the progestin level increases.

Perimenopause

Dr. Thomas said that the average age of menarche (first menstrual cycle) for girls is 11 years, and the average age that women experience menopause is 51 years.  Perimenopause is the period of time before the menstrual cycles stop completely, which may last 2 to 7 years.  During this time the woman may experience hot flashes, mood swings, menstrual irregularities and decreased libido, as well as other annoyances, including headaches.

Hormonal Headaches or Menstrual Migraines

What happens when hormones fluctuate in a woman’s body?  For many women, it triggers headaches.  Dr. Thomas told her audience about headaches triggered by different hormonal occasions, such as:

PMS Headache

·      Typical onset is 2 to 5 days prior to the menstrual period.

·      Headache improves once the menstrual period has begun.

·      Triggered by a drop in estrogen.

·      Some women develop a headache because of fluid retention.

Treatment Options for PMS Headache

·      Try taking additional estrogen (cream or patch) for up to 7 days.  There are 3 different estrogens, which may not all be covered on insurance formularies.  You can go to a compounding pharmacist to find an estrogen that is right for you.

·      Estrogen/Methyltestosterone for increased well-being, libido.  Comes in a tablet such as Estrotest.

·      Take NSAIDS (nonsteroidal anti-inflammatory drugs), such as ibuprofen (Motrin and Advil) and naproxen (Anaprox and Aleve) before and during the menstrual period.

·      Tamoxifen, an anti-estrogen, has been used to treat PMS headache.  Tamoxifen is usually prescribed to breast cancer patients to reduce their estrogen levels.

·      Danazol, an androgen (male hormone)—often used for treating endometriosis.

·      GNRH Agonists/Addback:  Used for endometriosis and fibroids.

Dr. Thomas told the group about Premarin, a well-known estrogen tablet used by menopausal women as part of their hormone replacement therapy (HRT).  Did you know that Premarin is made from the urine of pregnant mares?  That’s why it’s called “pre-mar-in.”

Hot flashes are a common signal that the female body is in perimenopause or menopause.  It’s important to remember that hot flashes are not a psychiatric disorder, they are caused by fluctuating hormones.  Hot flashes, or flushes, can cause a woman to experience poor sleep quality, increased irritability, increased conflict with partner or family members, increased depression or anxiety.  And the tendency to have hot flashes can last for years, while the body is getting used to the ever-lower levels of estrogen.

Pregnancy Headache

Dr. Thomas said that for women who experience headaches during pregnancy, they are usually worse in the first trimester, and also during the immediate postpartum period (right after the baby is born hormone levels are very unstable).  A pregnant woman can also be affected by her hydration status—nausea and vomiting can bring on dehydration, which can trigger a headache.

Treatment Options for Headaches During Pregnancy

·      Acetominophen with or without caffeine.  This can increase miscarriage rate, though.

·      Acetominophen with or without codeine.  Not recommended.

·      NSAIDS.  Not recommended because nonsteroidal anti-inflammatory drugs decrease the amount of amniotic fluid.  But Dr. Thomas added that a short course (2 to 3 days) is OK.

·      Antiemetics.  Anti-nausea medications can help headaches as well as nausea.

·      Midrin.

·      Betablockers.  Not recommended, though.

Menopausal Headache

When a menopausal woman begins taking hormone replacement therapy, there is a typical improvement in headache symptoms; but for some women, headaches may worsen with hormone replacement therapy.  In fact, HRT can actually precipitate headaches.

What is the best way to administer HRT if you suffer from headaches, pills or the patch?  Dr. Thomas explained that the patch is a better way of getting the estrogen to the blood stream.  It is better because the patch is longer-acting, and the levels of estrogen in the blood stream remains more constant.

Or you can use gels or creams, which are available from compounding pharmacists.  If you take estrogen by mouth, try putting the tablet under your tongue (sublingual) and allowing it to dissolve.  This gets the estrogen into the blood stream quickly.

Hormone Replacement Therapy (HRT)

What are the pros and cons?

Pros:

·      Hormone replacement therapy helps in preventing osteoporosis, or bone loss.

·      It slows dementia such as Alzheimer’s Disease, as it increases bloodflow in the brain.

·      It is the best treatment for hot flashes, though there are other treatments one can use to reduce the number and severity of hot flashes.

·      It treats vaginal dryness, another symptom of lowered levels of estrogen.

There is controversy now about whether HRT provides CV protection (cardio-vascular).  Doctors used to think it was the best thing for preventing heart attacks, but now they’re discovering that some women are harmed by using HRT.  Dr. Thomas said, “If you’ve been on estrogen for 10 years and haven’t had a problem with it, it’s probably OK.”

She stressed that if you’re a pre-menopausal woman, you should take at least 1,000 to 1,200 mg calcium per day.

Cons:

·      There appears to be a slightly greater risk of breast cancer in women who’ve taken hormone replacement therapy.

·      Weight gain is common in women on HRT.  It causes the body to retain fluids, there is breast tenderness, and your metabolism slows so you’ll gain weight if you continue to eat the same amount of food as before.

·      HRT can also be expensive.

Re-evaluate

Dr. Thomas stressed that it’s important for a woman on HRT to reassess the risks and benefits with her doctor every year.  She said we shouldn’t take HRT for 20 years.  Hot flashes usually go away in 2 to 5 years.  So, reassess yearly and either take away completely or modify your HRT regime.

Hot Flash Treatment Options

·      Estrogens do all the good work in the female body.  If you have a uterus and are taking estrogen, it’s important that you also take progestin.  But if you’ve had a hysterectomy, progestin is not needed.  Progestins mitigate the benefits of estrogen. 

·      Bellergal-S:  This is a compound (not hormonal) which can cause sleepiness and is slightly addictive.

·      Phytoestrogens:  These are found in soy products.  Phytoestrogens are better than taking a pill because they are absorbed better.

·      Black Cohosh:  A phytoestrogen that can be taken if headaches are triggered by HRT.

·      Antidepressants, such as Efixir.

Headache Treatment - Non-pharmacological Options

·      Keep a headache diary.  This will help when you visit your doctor because you’ll be able to accurately describe your headaches and your level of incapacity during them, and also how frequently you experience headaches.

·      Avoid food triggers.  Learn the most common foods known to trigger headaches.  Try to identify if eating any particular food seems to bring on headaches for you, and then stay away from it.

·      Avoid sleep deprivation.  Figure out your own threshold for sleep.  Go to bed and arise at about the same time each day.

·      Try relaxation/biofeedback techniques.

·      Exercise

- Endorphins (Mother Nature’s happy medicine) are released during exercise.

   - Builds muscle mass

    - Maintains overall health

 Headaches that are a sign of danger:

·      Sudden onset

·      Onset after age 50

·      Worst headache ever

·      Onset with exertion, sexual activity, coughing or sneezing

·      Focal neurologic signs are present

·      Abnormal medical symptoms are also present

Dr. Thomas finished her presentation and asked for questions from the audience.

Questions and Answers:

Q.  Can you take testosterone without estrogen for a decreased libido if estrogen triggers headaches?  The woman who asked the question explained that she gets paralysis with migraines, about twice a year, which are called complicated migraines.  She couldn’t take the Pill, had a hysterectomy with one ovary was left intact.  She doesn’t experience hot flashes, but dryness and loss of libido, and headaches.

A.  Dr. Thomas explained that testosterone provides a mild form of estrogen, and is available as an ointment from a compounding pharmacy (and also in pellets from UCSF and injections).  She advised that the woman get bloodwork done to see if she’s menopausal yet—her headaches could be triggered by fluctuation of hormones in the remaining ovary.  She could take something to stabilize her estrogen level; or she could maybe take something to knock out her menstrual cycle completely, but then her libido and dryness would get worse.  If she’s still perimenopausal, it should get better, Dr. Thomas added.

Q.  Testosterone—What about a pill?  One audience member commented that she takes testosterone for libido issues, brought on by taking an antidepressant.

A.  Dr. Thomas made the comment that “Everyone’s different so there’s no one treatment that will work for everybody.”  She said that HRT gives you a much lower dose of hormones than birth control pills.  If one’s FSH level is high, the ovaries are not making much estrogen, and the brain is overworking to get the ovaries to do their job.

How the birth control pill works:  It is progesterone-dominant, and makes the brain shut down the stimulation of the ovaries to make estrogen.

Q.  What studies have been done?  What other products are on the market?

A.  Fosamax is for women who have osteoporosis, but can’t take estrogen.  Actinal; Uvista (like Tamoxifen), but it makes hot flashes worse.  Dr. Thomas told the audience that there is no perfect medication—all have side effects, but you can usually find something that is tolerable.

Q.  Is there an increased risk for blood clots if taking phytoestrogens?

A.  Phytoestrogens provide the same effect as estrogen, and blood clot risk is lower than if using man-made estrogens for HRT.

Q.  Does temperature affect patch usage?

A.  Dr. Thomas answered that any extreme in temperature would affect absorption of the estrogen, and she added that patches are designed to withstand hot flashes.  (Of course, if you’re taking the right amount of estrogen, hot flashes should be greatly diminished.)

Comment by Dr. Michael Stein, medical advisor to the headache support group:  Some of Dr. Stein’s headache patients have sworn to him that their headaches became worse after they underwent tubal ligations.  Dr. Thomas responded that she also has many patients who’ve made this comment, but theoretically it doesn’t make sense.

Q.  One women asked if she can’t or won’t take estrogen, can she take micronized progesterone or cream?

A.  Dr. Thomas said the side effects of taking progesterone are:  Depression, bloating (diuretics are helpful, but won’t help depression), and headaches.  And she added that we must remember that progesterone is needed if estrogen is taken and the uterine is intact. 

If you’ve had a hysterectomy, then it’s safe to take unopposed estrogen.  Dr. Thomas doesn’t recommend taking Provera, a progestin, because it causes water retention.

Q.  How are menstrual headaches triggered?

A.  Either by a drop in estrogen level, or if estrogen level is too high.  Dr. Thomas said that everybody has their threshold—and we all have different body chemistry.

Dr. Stein mentioned a new strategy by doctors to extend the menstrual cycle out to 42, 63 or even 84 days, using birth control pills that include both estrogen and progesterone together.  Dr. Thomas said a woman normally takes a birth control pill for 3 weeks and then the 4th week it’s just a sugar pill (no hormone).  Using the new technique with the combination pills, she would take one every day for 3 weeks, plus 3 weeks, plus 3 weeks.  Dr. Thomas said there appears to be no harm to the body, but you might have a problem with your insurance company.  You could supposedly take this regimen indefinitely, but some women will experience spotting when taking both estrogen and progesterone together.

Q.  What about the triptans for combatting headaches?  Do you prescribe them?  (Imitrex, Amerge, Zolmig, Naratriptan, etc.)

A.  Dr. Thomas answered that she sometimes prescribes a triptan for a patient with migraine headaches.  But she added that she tries to correct hormone problems first to see if that will do the trick.

Q.  What about strokes caused by blood pressure, or a blood clot?  Does estrogen have anything to do with them?

A.  Dr. Thomas said that estrogen will affect strokes caused by blood clots, but not strokes caused by high blood pressure.  For some women, taking estrogen replacement therapy is not safe because of their tendency to make blood clots.

Q.  Is Imitrex unsafe to take if you have a history of thrombosis (blood clot)?

A.  Dr. Stein answered that the triptans are safe for a person who has thrombosis in their veins.

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.