HEADLINES
a pUBLICATION OF THE eAST bAY hEADACHE sUPPORt gROUP
a member of the American
Council for Headache Education (ACHE) support group network
VOLUME
6, ISSUE 5
SEPTEMBER 2001
September
11th Meeting:
Are Your Hormones Giving You
Headaches?
The East Bay Headache Support Group is once again pleased to have Dr. Sondra Altman, a gynecologist, as its guest speaker. 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.
Though Dr. Altman will be talking about female hormones and the role they play in triggering headaches in women, we encourage men to attend also to learn along with their partner about the major role hormones play in a woman’s life.
In addition, the Women’s Health Center is presenting a series of FREE evening lectures by area experts on women’s health issues. All lectures are held at the Women’s Health Center 7:00 to 9:00 pm, and reservations are required. To sign up, call 925-941-7900, Option 3.
Sept 10:
Oh, My Aching Head–Women and Headaches Michael
Stein, MD, Neurologist and Medical Advisor for East Bay Headache Support Group.
Sept
11: Keeping the Fires
Going–Sexuality Through Menopause Rob
Cole, MD, Ob/Gyn Lynne Forrette, Women’s Health Nurse Practitioner
Sept
12: Infertility Treatment
Options–Which One is Right for You? Reproductive Science Center, East Bay
Sept
19: Childhood Emergencies–What
Do You Do? Andrew Nash,
MD, Pediatrician
Sept
20: Uterine Fibroids and
Hysterectomy Steve Wells, MD, Ob/Gyn
Sept
24: Making Sense of Your
Options–Treatments for Menopause Sondra Altman, MD, Gynecologist
Sept
25: Osteoporosis–What Every Woman Should Know! Richard
Weinstein, MD, Endocrinologist, Medical Director Osteoporosis Center
Oct
3: Eating Disorders–Information
for Girls and their Families Deirdre
Moriarty, PhD, Concord Therapy Center
Hormones and
Headache: A New Frontier in
Migraine Research, By Vince
Martin, MD
Female hormones such as estrogen and progesterone have a profound effect on the brain and nervous system of women with migraine headache. Changes in these hormones that occur during a typical menstrual cycle likely account for the observation that migraine is three times more common in women than men. Virtually every reproductive life event—including the beginning of menstruation during teenage years (called the menarche), pregnancy, and menopause—has the potential to change the frequency, severity, or duration of migraine headache.
Hormonal
Changes During the Menstrual Cycle
There are dramatic changes in the levels of estrogen and progesterone in the bloodstream during a normal menstrual cycle. During the first 7-10 days of the menstrual cycle the levels of estrogen and progesterone are low. In the middle of the cycle (days 11-15) the estrogen level goes up and then falls abruptly, but progesterone levels remain low. This is when a woman ovulates. During days 16-25 the levels of estrogen and progesterone are high and relatively constant. Then right before the next menstrual period (days 26-28), the levels of estrogen and progesterone dramatically fall. The fall in progesterone leads to bleeding of the lining of the uterus and the start of the next cycle.
The peak levels of hormones can vary from one cycle to another in an individual woman. Also, the rates at which estrogen and progesterone rise and fall during a given menstrual cycle can change from month to month. Greater changes in these hormones could explain why some women have much worse migraines during a particular month. It’s possible that the progesterone that is made by the ovaries during the latter half of the menstrual cycle may actually prevent headache.
Past
Scientific Evidence
The “Falling Estrogen” Theory. Past scientific studies support the concept that a drop in female hormones triggers migraine headache, or menstrual migraine. Studies in the 1970s suggested that the fall in estrogen that occurs at the time of menstrual bleeding is responsible for these menstrual migraines. The fall of progesterone was not thought to play an important role in the triggering of migraine headache.
Migraine headaches also commonly occur during the “placebo week” of birth control pills when no estrogen is given. Falls in estrogen likely influence chemicals in the brain such as serotonin, adrenaline, dopamine, and endorphins. Changes in the activity of these brain chemicals likely trigger the development of migraine headache.
The “Serotonin” Theory. Before a migraine headache, serotonin levels appear to be low in the bloodstream and possibly within the brain. It is possible that this low level of serotonin may then lead to a migraine attack. Estrogen increases the production of serotonin in the body and also influences the way in which serotonin binds to nerve cells.
Recent studies have focused on the potential use of triptans to prevent menstrual migraine. The triptans include familiar migraine drugs such as sumatriptan (Imitrex), zolmitriptan (Zomig), rizatriptan (Maxalt) and naratriptan (Amerge). The chemical structure of these drugs resemble serotonin, so they are able to interact with the brain’s serotonin system. In theory, these medications could counteract the “low serotonin” state seen during the menstrual period. A recent study of Amerge (given twice daily for 5 days around the menstrual period) found that the frequency of menstrual migraine could be reduced by 50% when compared to a placebo treatment.
The “Prostaglandin” Theory. Prostaglandins, which are released as part of the body’s inflammatory response to injury or infection, have been shown to trigger headaches in patients with a history of migraine headache. Prostaglandins are produced by the uterus and released into the bloodstream during menstrual bleeding, so it is thought that they could have a role in menstrual migraine.
Nonsteroidal anti-inflammatory medications such as ibuprofen (Motrin) and naproxen (Anaprox and Aleve) block the production of prostaglandins. These medications have been shown in some studies to be effective in preventing menstrual migraine when taken daily around the time of the menstrual period.
Migraine
Prevention Through Hormonal Therapies
Many of the hormonal strategies to prevent menstrual migraine have focused on preventing the falls in estrogen that occur around the time of the menstrual period. For example, a woman can use an estrogen patch for 7 days around the time of her period to prevent this fall in estrogen. If a woman with migraine takes birth control pills, then she and her doctor can decide to try omitting the “placebo week” between two consecutive packs of pills. She will only have a menstrual period once every 2-3 months and therefore the number of menstrual migraines should decrease. It should be noted that long-term studies of this use of birth control pills have not been performed.
We recently completed a study in which a medication called goserelin (Zoladex–not available to the public as yet) was given to women who were still having menstrual periods. This medication “turned off” the ovaries, creating a medicine-induced menopause. Estrogen was then given back to the women in the form of an estrogen patch which maintained estrogen levels at relatively constant and low levels. Interestingly, the group of women who had received the estrogen patch had a significant decrease in the severity and disability of headache when compared to another group of women who had received a placebo estrogen patch. The results of this study would suggest that natural estrogen when given in constant low levels couldactually be a migraine preventive. These results should dispel the myth that all forms of estrogen can provoke migraine headache! In fact, some forms of estrogen may actually prevent migraine headache. The tendency of estrogen to provoke headache likely depends on the type, the route of administration, and the dose of estrogen used, as discussed below.
Estrogen
for Women with Migraine
Type of Estrogen. There are a number of types of estrogen, including conjugated estrogens (hormones obtained from animals that are chemically different from human estrogens), synthetic estrogens (estrogens that have been chemically modified and synthesized), and natural estrogens (estrogens identical to those produced by your body). Synthetic estrogens are found in birth control pills, while conjugated and natural estrogens are generally used in hormone replacement therapy given to women after menopause.
Synthetic estrogens are much more potent than the other forms of estrogen and are combined with a progesterone in birth control pills. Synthetic estrogens found in birth control pills often cause no discernable change in the pattern of migraine headache, but individual women can have an improvement or worsening of migraine while on birth control pills. Since synthetic estrogens are more potent, they are more likely to promote blood clotting and carry with them a very slight increased risk of stroke in women with migraine. The conjugated estrogens given to women during menopause have also been shown to improve or worsen migraine in various studies. Since natural estrogens were found to be effective in our study, it is our preference to use natural estrogens such as estradiol in women who decide to take hormone replacement during menopause.
Route of Administration. Estrogen can be administered in the form of a pill, a patch applied to the skin, an injection, or a vaginal cream. The route of administration becomes important because not all regimens maintain constant estrogen levels, which we believe are important to prevent migraine headaches. The estrogen patch maintains relatively constant estrogen levels in the bloodstream and thus is our preference for women during menopause.
Our second preferred route is the pill. Estrogen found in birth control pills can only be administered in a pill form. As a contraceptive, progesterone can be given as an injection (Depo-Provera) every 3 months or as an implant placed underneath the skin (Norplant). Headache is one of the most common symptoms encountered with these forms of contra-ception, and therefore we do not routinely recommend them to women with migraine.
Dose of Estrogen. Clearly the dose of estrogen is important in women with migraine headache who receive hormone therapy during menopause. It has been our experience that there is no one dose of estrogen that is most beneficial to all women with migraine. We often start with the lowest dose of estrogen and gradually increase it if necessary. There is likely an optimal dose of estrogen for each individual woman to minimize the number of migraines.
The “constancy of dosing” of estrogen may also be important in women receiving estrogen during menopause. In the past it was recommended that women should discontinue their estrogen for one week each month. This led to worsening migraine headaches during the week in which the women were not taking their estrogen (as a result of falling estrogen levels). For this reason, women with migraine should use hormone replacement therapy continuously during menopause without breaks.
When estrogen is given in the form of birth control pills, we try to use the pills with the lowest doses of estrogen. There is some scientific evidence to suggest that the risk of stroke is slightly higher in women with migraine who use birth control pills with higher estrogen doses. Many physicians would recommend caution in the use of birth control pills in women with migraine who have other risk factors for stroke, such as smoking, age over 40, migraine auras with neurologic symptoms (weakness, paralysis, etc.), high blood pressure, or elevated cholesterol.
Summary
Female hormones can play an important role both in triggering and possibly in preventing migraine headache. Evolving scientific evidence would suggest that estrogen therapy itself is not the “bad guy,” as previously thought, in women with migraine. When administered in the appropriate fashion, estrogen can be given safely and with minimal side effects for those women requiring its use.
Vince Martin, MD. Division
of General Internal Medicine, University of Cincinnati, Cincinnati, OH.
Condensed from HEADACHE: Newsletter of
the American Council for Headache Education - Summer 2001