Headlines
A Publication of the East Bay Headache Support Group
A Member of the American Council for Headache Education (ACHE) Support Group Network
Volume 4, Issue 8
August, 1999

Headaches—A Pain in the Neck!

Remember the children’s song,"The head bone’s connected to the neck bone, the neck bone’s connected to the back bone..."?

The meeting is Tuesday, August 10th, from 7:30 to 9:00 pm in the Ball Auditorium at John Muir Medical Center. For more information, call (925) 938-5252.

Editor’s Note: Hang in there, guys. Our July meeting was about women’s hormonal triggers, and following is an article about menopause. But we promise next month’s newsletter will feature articles for both genders. And ladies...check out our notes on hormone-induced headaches from the September 1996, March 1998, and July 1999 meetings.

Menopause, that once only whispered about "change," has become a hot topic everywhere, including the headache specialist’s office. Some of this is due to sheer numbers, as the first wave of the baby boomers, that vocal and involved group, passes into its fifties. These women often aren’t occupying the traditional roles in society. Instead of waiting out the hot flashes in the bedroom, they need and expect to stay functional in the boardroom, classroom, or courtroom—or to stay active and involved with family, friends and community.

With the advent of hormone replacement therapy (HRT), menopause itself has changed. Whereas our mothers and grandmothers all had to go through the natural process in more or less the same way, women today have a sometimes confusing array of hormonal options that can shorten, prolong, or otherwise alter any of the menopausal symptoms—including migraines.

Answers to the questions and dilemmas posed by menopause and HRT can be frustratingly difficult. Scientific studies, as with all too many women’s health concerns, have been in somewhat short supply until very recently. Individual differences among women tend to be large, anyway, so that studies and statistics may not be as helpful as we would like.

We do know that the peak age for migraine among women is around 35 to 40, and overall the trend after that is for continued improvement into old age. With natural menopause, about two-thirds of women report an improvement in their migraines. Women who had a strong pattern of menstrually-associated migraines are the most likely to improve. This is likely because the hormonal trigger for menstrual migraine in younger women involves an abrupt drop in estrogen from a previously high level, the normal pattern in the cycle just before menstruation. As hormone levels become constantly low in menopause, there is no opportunity for such a drop, and so the hormone-triggered migraines disappear.

As many women go through menopause, though, instead of a hoped-for smooth transition, they notice that their periods and migraines become more irregular and more troublesome. It is likely that there are several more factors at play, including other hormones such as progesterone, other body chemicals, or just change it-self. Just as abrupt changes in sleep and diet habits can bring on migraines, changes in hormone levels in any direction may be hard to tolerate for some women with migraine.

So what does this mean when it comes to deciding about whether or not to use HRT? In fact, the usual estrogen replacements have been reported to both help and worsen migraines, with large individual variations. It remains at this point virtually impossible to predict what a given woman will experience with a particular hormone. Even her previous experiences with birth control pills many not predict the effects of HRT, since the actual hormones and strengths can vary considerably.

It is probably best, then, for a woman and her doctor to decide on trials of HRT based on her other medical risk factors. Women at high risk for osteoporosis and heart disease, for example, would probably want to try HRT, while those with a personal or family history of breast cancer may not. Then, if the migraines do worsen on HRT, there are some hormonal manipulations that might prove useful.

The dose of estrogen can be manipulated up or down. Generally, the lower doses are recommended for migraine, although there may well be some tradeoff with other menopausal symptoms such as hot flashes. Most women are capable of deciding what dose works best for them, with a little guidance from the doctor.

Since the change in hormone levels may be a trigger, switching from cyclical to continuous dosing may be useful. The more traditional HRT regimen involves using progesterone part of the month to induce menstrual bleeding, which helps protect against uterine cancer. There are new combination hormones and steady dosing patterns, though, that may be appropriate for some women, again with the guidance of their doctors.

The most common type of estrogen prescribed is a natural extract from horses (Premarin and others). The content of these preparations is not as exact or controlled as many of the synthetic or single-chemical estrogens available, and may be more likely to trigger migraines. Similarly, it has been suggested that the patch forms of estrogen supplementation may release their chemicals more smoothly than do pills. The idea in both cases is to avoid variations in estrogen levels that might trigger a migraine.

We tend to think of HRT in terms of estrogen since it is the major hormone involved, but HRT is often given as a combination of different hormones. Some women may improve when progesterone is eliminated entirely, or when testosterone is added. There are also a few reports that a new selective estrogen-like agent (called raloxifene or Evista) may have fewer headaches associated with it than with regular estrogens, but it is too new to evaluate fully and has some other drawbacks. Again, a decision to try such a drug would depend on an individual woman’s needs and risk

I vividly remember as a child seeing my mother with a bandana wrapped around her head and knowing she was having one of her headaches. And I remember asking questions about my father, who was killed in WW II. My mother told us he suffered terribly from headaches. He would come home from work and want us children in bed, asleep, because his headache was so severe. I remember we had to be especially quiet and good, and I always thought that wasn’t very nice to make us go to bed so early. But I knew nothing about headaches then and the excruciating pain they cause.

After all, nobody thought it bad enough to seek medical help or talk much about it. Headaches were considered a minor affliction. Actually, if you didn’t want to be looked upon as a sissy it was best not to mention it to anyone. I think I was about sixteen when I began experiencing head-aches, but it is quite possible that I may have had some when I was much younger, as my mother told me I would often come home from school, refuse to eat, and just go to bed. Because of what I had seen and heard at home I suffered in silence. I learned you just don’t tell anyone when you have a headache nor do you seek medical advice.

There was a period in my life when the headaches did not bother me very much, but when I was around 35 I could not ignore them any longer. Besides the pain, I also became aware that sometimes I would use the wrong word in conversation. Sometimes this was amusing, but more often it was embarrassing. I was spending long hours in front of a computer, and writing and reading, so I had my eyes checked to see if eyestrain could be the cause of all my recent headaches. Wearing glasses didn’t make a difference, however.

A couple of years later during my physical exam I mentioned the headaches to my physician and was given codeine, which helped for awhile. Then it became apparent to my co-workers that I was in pain. When I explained I had headaches they suggested many tips to relieve them, like putting your arms in warm water, taking a very hot shower, visualization, positive thinking, and drinking coffee. Nothing helped me. At times I had so much pain that I couldn’t remember how I got home. All I longed for was quiet and darkness.

At my next physical I knew I had to tell the doctor how strong and debilitating the headaches had become. "Ah," he said, "what you have is called a cluster headache." What a relief to hear that finally a physician knew something about headaches and maybe a treatment. All I wanted was to not lose so many days out of my life because of a headache. He prescribed Cafergot, but the trick was to take it before the onset. This marked the beginning of trying to become aware. In the past I would just say to myself, "Oh, God, not another headache," but now I was trying to figure out when it began. My best clue was mixing up words. I also figured out that just before the onset of pain I would see an aura, get very sleepy and short-tempered, and things would easily upset me. Cafergot helped sometimes, but not often enough, so I still had to contend with one headache a week. And by now I had developed monster headaches. Often I would throw up.

Now I was on a quest to learn more about this ailment. At first I couldn’t find much information about migraines—it seemed at that time that people did not talk about it or take it seriously. Later I attended a seminar in San Francisco on headaches, where I learned that many people suffer from what was referred to as migraines. I came to the conclusion that you cannot talk yourself out of a migraine, that it is not your fault and you are not a sissy if you get migraines. And this was also the first time I heard that migraines are hereditary—that bit of information set me free from feeling guilt. From that moment on I stopped hiding my pain. No longer was I ashamed to say to my husband, "Honey, I have a migraine." Little by little I found more information in print about this malady.

Years passed, with a little relief, but not enough. I was still plagued and suffering, but it was tolerable. Whenever I heard of something someone was taking, I would ask my doctor to prescribe the same for me. Nothing really helped me much. It seemed to be hit-and-miss most of the time. I also took over-the-counter medication, in larger quantities over many years.

Then something happened. Maybe meno-pause or just getting older. The migraines reared their ugly heads to a point where I thought surely I must have a brain tumor. I had a headache for weeks on end, it just wouldn’t go away. I could barely function. The pain was so severe that I wished I could die.

I spoke to someone about this relentless, agonizing pain in my head and it was suggested I go see Dr. Michael Stein, a head-ache specialist. He took me seriously. It was a relief to hear him say that I did not have a brain tumor, but was suffering from classic migraines—and had now developed a rebound headache from all the medication I pumped into my body. He asked me many questions. "What do you feel before they begin? How often do you have them? Did either of your parents have headaches?" And many more. He then suggested I keep a diary, which I did. Really helpful for me was becoming aware of triggers. This was the first time I heard of triggers.

All seemed to spell "hope" for me. Hope that maybe I can live a life free of head-ache pain. Mind you, I can stand a little suffering, but by then I was pretty bad off. This was the light at the end of a tunnel.

I still get migraines, but I know they are manageable—I don’t have to suffer 3-4 days before they go away by themselves. We are no longer so much in the dark about migraines. More information is now available about this beast. Because we are all unique and different we suffer migraines differently, but there are many common denominators. Let’s keep on talking and listening to everything that is now known about migraines. For me, it is staying away from wine and chocolate. This is a small price to pay to ward off a debilitating migraine.

Whoever said "Ignorance is bliss" never suffered from migraines. I believe for us, knowledge is power. Power to prevent and power to cure. ‡