MARCH 2005 MEETING NOTES

TOPIC:  “HEADACHES AND HORMONES”

The East Bay Headache Support Group meeting on March 8, 2005 featured Dr. Sondra Altman, a Walnut Creek gynecologist.  Dr. Altman gave wonderful presentations to the support group several times in the past, and this was no exception.  Twenty-three attended the meeting, held in the Ball Auditorium at John Muir Medical Center.

Dr. Altman began her presentation stating that she wanted to cover at least the following three topics—all things that can bring on headaches in a woman:

Menstrual Cycle

She gave a quick description of the menstrual cycle and said that estrogen starts out low, rises and then peaks, and then drops.  Cells around the egg become a progesterone factory.  She said it’s the dropping of hormone levels that brings on a period.  And rapidly dropping estrogen level causes instability.

Dr. Altman’s patients have told her that their menstrual migraines (headaches that occur just before or during their periods) are different and don’t respond to their usual migraine medications.  She said a treatment is to bring the estrogen level back up.  You can carry a bottle of estradiol and take a tablet, grind it up and absorb it under the tongue for quick relief of a menstrual migraine.  If your migraine is the result of a drop in estrogen, this treatment can work in 20 minutes.  Or you can slap on an estrogen patch (4-day or 1-week variety).  She said that this extra estrogen doesn’t give you too much, it just helps with the drop in estrogen.  If you have a regular menstrual cycle and frequently experience menstrual migraines, she suggested that you add an estrogen patch or take it orally ahead of time—before the migraine strikes.

Birth Control Pills

Some women find that birth control pills cause headaches.  The majority of women taking the Pill get headaches during the week their daily pill is a placebo only (no estrogen).  Dr. Altman suggested that rather than discontinuing using the Pill, that you try a different one.  There are now some that are taken daily for 12 weeks and then you take a one-week break without estrogen.  Or instead of taking the placebo pills for one week, you can take an oral estradiol instead.  In a pre-menopausal woman, she said that the highest dose estrogen patch will not stop your period.

Is it OK not to have a period?  Dr. Altman said that it’s OK because when taking the Pill, the uterine lining doesn’t get thick and periods tend to be light.

Dr. Altman said that using the birth control patch or a vaginal ring is the best as far as stability of the hormone levels.  She thinks the best is using the birth control patch for 3 weeks and then using an estrogen patch for 1 week.  “Stability is a beautiful thing, and nature doesn’t give it to us.”  The birth control ring has progesterone and a lower amount of estrogen, and you receive the same amount every day.  Birth control pills are all completely synthetic, with a variety of progesterones in them.

The average age of menopause for women in the US in 1900 was 47.  And the average age for death back then was 48.  Now women are living much longer after menopause.  Also, women today have many more periods (400+) than women in primitive cultures (120), largely because of fewer pregnancies.

If you are sensitive to hormonal shifts, you need stability.  For a woman sensitive to dropping estrogen levels, going through the change (menopause) can be a nightmare.

Talking about the menstrual cycle again, Dr. Altman said that no matter how long your cycle is, you will always get your period 14 days from ovulation.  But the first part of the cycle can be shorter. 

As you are headed for menopause, the peaks are lower and valleys are lower.  You can get more headaches—vascular instability.  Doctors will prescribe birth control pills, but you won’t be able to cope with the off (no estrogen) week.  But you can use an estrogen patch during this week.

Hormone Replacement Therapy

The median age for menopause in the US is 51.3 now.  By age 55, 95% of women are done with their periods.  So she said that somewhere between the ages of 53 and 55 you should switch to HRT to offset the drop in estrogen.  But you have to be a non-smoker.  Dr. Altman made the statement that, in her opinion, a smoker deserves to get a headache. 

Dr. Altman mentioned the Women’s Health Initiative which determined that HRT was dangerous for women.  Dr. Altman disagrees.

She then told us about a woman who woke up every morning with a dull headache.  She was taking Premarin once a day, which lasts 20 hours in the system.  But there are 24 hours in a day.  Therefore, the last 4 hours she would experience a drop in estrogen, which would bring on a headache.  She also experienced night sweats only in the last 4 hours.

Dr. Altman mentioned Synaptin (senestin), a vegetarian (soy) time-released method of hormonal replacement therapy.  She said it has a 4-hour rise, 15-hour plateau, and a 4-hour drop.  The only oral HRT she would give a migraineur is Synaptin.  She exclaimed that “Hormonal stability is wonderful!”  If you can absorb your HRT through the skin, it’s better.

Estradiol is natural estrogen.  There is a chemical process that turns soybeans into estradiol.  Dr. Altman recommends not going to a compounding pharmacist if instability is a problem.

She talked about 3 methods of HRT:  a patch, a gel spread on your arm, and a vaginal ring (lasts 3 months).  These don’t increase the risk of blood clots or influence markers (stroke), don’t increase triglyceride levels in the blood, and don’t reduce testosterone.

If you are taking HRT, Dr. Altman said she wouldn’t advise anyone to stop cold turkey.  Most women who stop HRT abruptly have an unpleasant experience.  She said that a lot of women who came back to HRT find they need less—maybe only a half a patch.  She stated that estrogen is important for bone density.

Dr. Altman then asked the audience for questions.

Q.  Have you had experience with Effexor?

A.  She responded, “Effexor for hot flashes; for headaches no.”  She went on to say that “Everything works for a month.” (placebo effect)

Q.  What about progesterone?

A.  Dr. Altman answered, “If progesterone is my friend, why does it give me PMS (premenstrual syndrome)?”  The old rule is that progesterone has to be taken to balance the estrogen.   She said that Premarin is prescribed to be taken on Days 1 through 25.   Then Provera is taken.  She made the comment that, “Provera can give PMS to a tree.”  We’ve lowered the dose, now what?  Estrogen increases estrogen receptors, both in number and how sensitive they are.  Progestin decreases estrogen receptors and makes them less sensitive.

Dr. Altman has patients who bargain with progestin.  They want to go longer without it so they don’t have headaches and PMS.  Some take Prozac the days they have to take progesterone.

Dr. Altman said that 10% of women go through menopause with no symptoms.  If you’re one of the other 90%, there is help.  On the Internet, visit www.drugstore.com.

Q.  One woman in the audience said she has had hot flashes for 8 years (she’s 58 now) and her Kaiser doctor only gives her Premarin. 

A.  Dr. Altman said she should tell her Kaiser doctor that Premarin gives her headaches.  She also said that Kaiser just switched to prescribing oral estradiol (instead of Premarin), but that is also not good for migraineurs.  Kaiser gives HRT based on what contract they have (price), not on what’s best for their patients.  She said that a month of Premarin costs Kaiser only 11 cents.

Q.  One audience member complained of hormonal migraines and asked what to do.

A.  Dr. Altman said she should have her estrogen levels checked.  “If 100 or lower at a peak time, it’s not right.” 

Q.  One woman described herself as 4 years past menopause, but she still feels Mittelsmerz (that twinge of pain some ovulating women feel when the egg pops out of the ovary each month).

A.  Dr. Altman said it is probably “phantom” cycles she’s experiencing.  Dr. Altman commented that menopause is worse than puberty.  Neurontin is an anti-epilepsy drug.  A young doctor discovered that it controls both hot flashes and headaches.

Q.  An audience member said she always has a 2-day warning before her next migraine— she has hot flashes.  She goes crazy, and then her headache appears.  Her doctors tell her it sounds like the flu.

A.  Dr. Altman suggested that she add an estrogen patch those 3 days.  It may take time to figure out the right dosage. 

"Your FSH goes up when the estrogen level goes up.  If you are given a hormone test and the FSH result is 40.5, then you’re menopausal.”  Dr. Altman added that traditional teaching is “It’s not over until you haven’t had a period for a year.”  She said that now we meet women where they’re symptoms are.  

Q.  If your thyroid changes and you have to go on thyroid medication, can it upset your hormone balance?

A.  Estrogen can affect thyroid, but she’s not sure if thyroid affects estrogen.  She said there is an interplay.  The problem is—the symptoms are identical.

Q.  Dr. Stein, medical advisor to the headache support group, asked “What about headache and pregnancy?”

A.  Dr. Altman replied, “By and large, headaches are better during pregnancy…probably because the estrogen level is high.  She added, “Women are estrogen junkies.  A woman who feels great during pregnancy will have a hard time with menopause.”  Women should be aware that if they experience headaches in pregnancy, it could be pre-eclampsia which could be serious.

Q.  Dr. Altman was asked to comment on young teenagers with irregular periods and cramps.

A.  She said that teenage girls don’t ovulate regularly for the first 2 years.  She’s seen teenagers with miserable cramps and PMS.  She added, “these are hormonally uncontrolled bleeding episodes, not menstrual cycles.”

Dr. Altman was thanked for her presentation on hormones.  Then Dr. Stein advertised 2 new studies that his office is conducting on migraineurs.  He is seeking volunteers to be involved in a study of women with very difficult to treat menstrual migraines, and in a study of adolescent migraines (boys or girls).

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.  These notes were taken by a lay person, not a medical professional.

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