MARCH 2006 HEADACHE SUPPORT GROUP MEETING

TOPIC:  “MIGRAINES AND MENSTRUAL CYCLES”

Dr. Sondra Altman returned to speak to the East Bay Headache Support Group on March 14, 2006.  28 were in attendance at the meeting held in the Ball Auditorium at John Muir Medical Center.

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 Dr. Altman said, they may not accurately portray the information she presented to the group.  If you have questions about a possible link between your menstrual cycles and headaches, consult your personal physician.

Dr. Altman used PowerPoint slides to illustrate her presentation.

Slide 1:  Definition of menstrual migraine—usually occurs premenstrually, with no aura, and occurs in 2 out of 3 cycles.

Slide 2:  Mid-cycle drop in estrogen is steeper, but not as bad for migraineurs—maybe because of progesterone.

More estrogen—increases estrogen receptors and makes them more sensitive, and vice versa for progesterone.

Slide 3:  Prevention of migraine.  60% of migraines in women are hormonally related.

Slide 4:  Pathophysiology. 

Slide 5:  Acute therapy:

-- Triptan medications

-- Sublingual estradiol.  Dr. Altman explained that Estrace crumbles quickly under the tongue.  In 15 minutes it should get rid of your headache…if it’s hormonally related.  But the estrogen will peak and drop in 4 hours and you’ll get another headache.  So, 2 hours later, swallow an Estrace.  She said to use Estrace specifically, and not generic estradiol as it doesn’t crumble if you put it under your tongue—instead it just gets gummy.  The price is $20 to $30 for 30 tablets of Estrace.  Dr. Altman suggested that if you suffer from hormonally related migraines you should carry Estrace tablets in your purse for emergencies.  She added that you can use 3-5 per cycle to keep the hormonally-related headache away.

Slide 6:  Prevention.  Dr. Altman recommends the patch for prevention of hormonally related migraines.  She explained that the patch blunts hormonal fluctuations that trigger migraines, but she added that it won’t affect your menstrual cycle.  She recommends a 0.1 mg patch as a preventive.  Dr. Altman stressed that there is no harm to a woman if she still makes her own estrogen and adds more—however, she’s not talking about women 10 to 20 years past menopause.

The concept of using continuous birth control pills is old—actually it was used 30 years ago for endometriosis patients.  Dr. Altman explained the traditional delivery of birth control pills:  Three rows (weeks) of pills and one row of placebo so you get your period.  Pill periods are light, easy, predictable and regular because progesterone tells the endometrial lining not to thicken.

Seasonale:  This is a 12-week pill pack, which will bring on a period once every 3 months.  If periods were held off any longer, then many women would experience breakthrough bleeding.  Dr. Altman stated, “In any pill, progesterone wins.”

Two tricks suggested by Dr. Altman: 

#1:  Stop taking the pill and use the patch.

#2:  Keep going and add the patch.

Mircette:  This birth control pill has a novel dosage regimen which reduces the daily estrogen dose.  The dosing begins with 21 days of estradiol (and desogestrel), and then the 4^th week you take 2 days of placebo pills, followed by 5 days of a lower dose of estradiol (estrogen).

Vaginal Ring:  Today’s birth control pill has 30 micrograms estrogen.  Compare this to the birth control pills back in 1960 which had 180 micrograms estrogen in them.  But the Rind provides only 15 micrograms estrogen.  It is a thin ring which releases the same amount of estrogen each day.

If you are sensitive to hormonal fluctuation, Dr. Altman cautioned that any orally ingested pill has a peak and a valley.  But the ring is stable.  The ring has an extra 10 days—put in the first day of each month—whereas the pill has an extra 2 days.

7^th and last slide:  Perimenopause:  you really need to take over the situation because hormones fluctuate now.  Estrogen withdrawal triggers it.

Upon finishing her presentation, Dr. Altman asked for questions from the audience.

Q.  Which estrogen can you put under the tongue? 

A.  Estrace, which is now to be made as slow-release, which of course defeats the purpose of sublingual dosing.  Dr. Altman suggested that Gynediol might work.  She warned against using generics.

Q.  One audience member said that she is 6 years after menopause, but is still getting regular migraines.  What can she do?

A.  Dr. Altman suggested that she try the sublingual Estrace to see if it gets rid of her  migraines.  “Maybe you’re experiencing a phantom cycle,” she added.

Q.  What about estradiol cream?

A.  Dr. Altman answered that estradiol cream is not absorbed into the bloodstream, so it won’t help with migraines.  She said, “It’s not the estrogen—it’s the withdrawal from estrogen that triggers migraines.”  And she continued, “BC (birth control) patches have a more consistent level.  BC estrogen is always synthetic estrogen.  The only natural method of birth control is rhythm.

Q.  A participant reported that she gets night sweats and the patch falls off.  What can she do to keep it on? 

A.  Dr. Altman stated, “If you wake up with night sweats, you’re running out of estrogen.”  She said to make certain the skin is dry before applying the patch, and to use a blow dryer to dry the skin first.  She also said to brush baby powder over the patch to help it stick.

Q.  Dr. Altman was asked where the patch should be applied.

A.  And she answered, “On your body usually where your normal underwear covers.”

Q.  How do you tell if it’s a menstrual migraine?

A.  Dr. Altman answered that a menstrual migraine occurs up to 2 days before the flow  or up to 3 days into the period.  She added that most women can tell the difference between their menstrual migraines and other headaches, as hormonally-related migraines are worse and their medications don’t work as well.

Dr. Altman said if you’ve had a hysterectomy, but still have ovaries, the body has no clue that you’ve had a hysterectomy.  She said to mark 4 weeks on the calendar and keep track.  Then you can deal with it, i.e., know when to expect your next menstrual migraine.

Birth control pills suppress release of eggs.  A female embryo has 13 million eggs, and when she’s born she has 3 million eggs.  But she’ll be down to 200,000 eggs once she starts using them (menstruation starts).  Aging ovaries don’t make estrogen like they used to—the valleys are lower and the peaks are lower.  And migraines are not as regular also.

All birth control pills are synthetic.  There is no plant product that can produce mammalian estrogen.  Soybeans and yams do not contain estrogen.

Dr. Altman asked the audience if they knew how Premarin, the pill once widely used for hormone replacement therapy, is made.  Premarin actually is pregnant mare’s urine.

Dr. Altman uses 15 different estrogen products on post-menopausal patients.  And she added that progesterone can be made from Chinese yams and Mexican cactus.

Q.  What about Depo-Provera injections?

A.  Dr. Altman answered, “Ooh, that’s a 3-month migraine.  You’ll suffer menopausal symptoms for 3 months, as it flatlines your estrogen production.”

Q.  Dr. Stein asked about women who have been told to have a hysterectomy and oophorectomy to get rid of their migraines.

A.  Dr. Altman responded that she’s had a total of 10 patients who’ve had their uteri removed and discovered their migraines disappeared.  But don’t count on it to work.

Q.  Is high blood pressure a concern with the patch?

A.  Dr. Altman answered, “No, but hormone replacement therapy (HRT) can make your blood pressure go up.”

Q.  What about cancer?

A.  Dr. Altman stated that the incidence of ovarian cancer in women over age 70 is 2.4%, versus an 80% prostate cancer incidence in men over 80.  New thinking on cancer prevention—the ovaries stay unless there is a family history of ovarian or breast cancer.

Dr. Altman then explained that the Women’s Health Initiative looked at women who were 20 years beyond menopause.  They never studied any women under the age of 50.  She said that 25% of women need a small amount of HRT.  She added that suffering is a bad thing.  Not sleeping is worse than anything you’ll get from HRT.

Gels and cream—have only been on the market for about 18 months.  She said, “If you can’t use the patch because of sensitive skin, try a gel or cream form of estrogen.”

In conclusion, Dr. Altman made this comment:  “Peaks are a problem and valleys are a problem.  Being stable is better.”

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.