Unique Populations with Episodic Migraine: Pregnant and Lactating Women

POTS and Pregnancy: A Review of Literature and Recommendations for Evaluation and Treatment

Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system most commonly affecting women of reproductive age. Studies on POTS and pregnancy are limited, and there is a lack of clinical guidelines regarding assessment and management of pregnant women with POTS. The purpose of this review is to summarize data from the available studies on the topic of pregnancy in POTS and common comorbid conditions and to provide the clinical recommendations regarding evaluation and treatment of POTS in pregnant women, based on the available studies and clinical experience. We conclude that pregnancy appears to be safe for women with POTS and is best managed by a multi-disciplinary team with knowledge of POTS and its various comorbidities. Importantly, large, prospective studies are needed to better delineate the course and outcomes of pregnancy, as well as possible pregnancy-related complications in women with POTS. Clinicians should be aware of the clinical presentation, diagnostic criteria, and treatment options in pregnant women with POTS to optimize outcomes and improve medical care during pregnancy and post-partum period.

Giving Researchers a Headache - Sex and Gender Differences in Migraine

Migraine is a common neurovascular disorder affecting ~15% of the general population. Ranking second in the list of years lived with disability (YLD), people living with migraine are greatly impacted by this especially burdensome primary headache disorder. In ~30% of individuals with migraine, transient neurological symptoms occur (migraine aura) that further increase migraine burden. However, migraine burden is differential with respect to sex. Though one-year prevalences in childhood are similar, starting with puberty, migraine incidence increases at a much higher rate in females than males. Thus, migraine over the life course occurs in women three to four times more often than in men. Attacks are also more severe in women, leading to greater disability and a longer recovery period. The sex disparity in migraine is believed to be partly mediated through fluctuations in ovarian steroid hormones, especially estrogen and progesterone, although the exact mechanisms are not yet completely understood. The release of the neuropeptide calcitonin gene-related peptide (CGRP), followed by activation of the trigeminovascular system, is thought to play a key role in the migraine pathophysiology. Given the burden of migraine and its disproportionate distribution, the underlying cause(s) for the observed differences between sexes in the incidence, frequency, and intensity of migraine attacks must be better understood. Relevant biological as well as behavioral differences must be taken into account. To evaluate the scope of the existing knowledge on the issue of biological sex as well as gender differences in migraine, we conducted a systematized review of the currently available research. The review seeks to harmonize existing knowledge on the topic across the domains of biological/preclinical, clinical, and population-level research, which are traditionally synthesized and interpreted in isolation. Ultimately, we identify knowledge gaps and set priorities for further interdisciplinary and informed research on sex and gender differences as well as gender-specific therapies in migraine.

Managing migraine in pregnancy and breastfeeding

The disproportionate prevalence of migraine among women in their reproductive years underscores the clinical significance of migraine during pregnancy. This paper discusses how migraine evolves during pregnancy, secondary headache disorders presenting in pregnancy and puerperium, and acute and preventive options for migraine management during pregnancy and lactation. Migraine is influenced by rising estrogen levels during pregnancy and their sharp decline in puerperium. Migraine, and migraine aura, can present for the first time during pregnancy and puerperium. There is also a higher risk for the development of preeclampsia and cerebrovascular headache during these periods. New or refractory headache, hypertension, and abnormal neurological signs are important "red flags" to consider. This paper reviews the diagnostic utility of neuroimaging studies and the risks of each during pregnancy. Untreated migraine can itself lead to preterm delivery, preeclampsia, and low birth weight infants. Behavioral interventions and lifestyle modifications are the cornerstone for migraine treatment during pregnancy. In addition, one should consider the risks and efficacy of each treatment during pregnancy on an individual basis. The protective nature of breastfeeding for migraine is debated, but there is no evidence to suggest breastfeeding worsens migraine. Acute and preventive migraine treatment options are available for nursing mothers. Neuromodulation and neurostimulation devices are additional options for treatment during pregnancy and lactation, while the safety of using calcitonin gene-related peptide receptor antagonists during these times remains to be determined.

Migraine during pregnancy and in the puerperium

Pregnancy can be seen as a positive time for women migraineurs because the elevated estrogen and endogenous opioid levels raise the pain threshold and the stable hormone levels, which no longer fluctuate, eliminate a major trigger factor for the attacks. In a great majority of cases, indeed, migraine symptoms spontaneously improve throughout pregnancy. Generally, migraine without aura (MO) improves better than migraine with aura (MA), which can occur ex novo in pregnancy more frequently than MO. After childbirth, the recurrence rate of migraine attacks increases, especially during the first month; breastfeeding exerts a protective effect against the reappearance of attacks. Migraine and pregnancy share a condition of hypercoagulability; therefore, attention must be paid to the risk of cardiovascular disorders, like venous thromboembolism and ischemic or hemorrhagic strokes. Some of these diseases can be linked to preeclampsia (PE), a serious complication of pregnancy, characterized by hypertension, proteinuria, or other findings of organ failure. This condition is more common in migraineurs compared with non-migraineurs; furthermore, women whose migraines worsen during pregnancy had a 13-fold higher risk of hypertensive disorders than those in which migraine remitted or improved. Pregnancy is generally recognized to exert a beneficial effect on migraine; nonetheless, clinicians should be on the alert for possible cardiovascular complications that appear to be more frequent in this patient population.