Estrogen replacement and migraine

Hormonal therapies in migraine management: current perspectives on patient selection and risk management

INTRODUCTION

The link between sex hormones and migraines has long been investigated but the mechanisms underlying this altered interaction are not yet fully understood. Herein, we retrace the knowledge on this association in relationship with risk of stroke.

AREAS COVERED

Estrogens fluctuations could trigger migraine attacks and exogenous estrogens intake could be a risk factor for venous thromboembolism (VTE) and stroke. At the same time, ischemic heart diseases and stroke share a common substrate with migraine and other mood disorders, depression, and anxiety.

EXPERT OPINION

The use of hormonal therapies in the context of contraception or replacement therapy must be closely evaluated in a careful risk assessment. We highlight the complex interaction of hormone/neuroinflammation pathways underlying the pathophysiology of migraine glimpsing in mood disorders a possible common denominator of link between hormonal and neuronal systems.

The Connection Between Patent Foramen Ovale and Migraine

"Observational studies have identified a relationship between patent foramen ovale (PFO) and migraine headache. In people who have migraine with aura, 40% to 60% have a PFO, compared with 20% to 30% in the general adult population. It is hypothesized that migraine, especially migraine with aura, may be triggered by hypoxemia or vasoactive chemicals (eg, serotonin), which are ordinarily metabolized during passage through the lungs. Although PFO closure is currently not a FDA-approved therapy for migraines, randomized trials suggest that this intervention may benefit a subgroup of migraineurs."

Male and female sex hormones in primary headaches

BACKGROUND

The three primary headaches, tension-type headache, migraine and cluster headache, occur in both genders, but all seem to have a sex-specific prevalence. These gender differences suggest that both male and female sex hormones could have an influence on the course of primary headaches. This review aims to summarise the most relevant and recent literature on this topic.

METHODS

Two independent reviewers searched PUBMED in a systematic manner. Search strings were composed using the terms LH, FSH, progesteron*, estrogen*, DHEA*, prolactin, testosterone, androgen*, headach*, migrain*, "tension type" or cluster. A timeframe was set limiting the search to articles published in the last 20 years, after January 1st 1997.

RESULTS

Migraine tends to follow a classic temporal pattern throughout a woman's life corresponding to the fluctuation of estrogen in the different reproductive stages. The estrogen withdrawal hypothesis forms the basis for most of the assumptions made on this behalf. The role of other hormones as well as the importance of sex hormones in other primary headaches is far less studied.

CONCLUSION

The available literature mainly covers the role of sex hormones in migraine in women. Detailed studies especially in the elderly of both sexes and in cluster headache and tension-type headache are warranted to fully elucidate the role of these hormones in all primary headaches.

Structural and functional brain changes in perimenopausal women who are susceptible to migraine: a study protocol of multi-modal MRI trial

Background

As a common clinical symptom that often bothers midlife females, migraine is closely associated with perimenopause. Previous studies suggest that one of the most prominent triggers is the sudden decline of estrogen during perimenopausal period. Hormone replacement therapy (HRT) is widely used to prevent this suffering in perimenopausal women, but effective diagnostic system is lacked for quantifying the severity of the diseaase. To avoid the abuse and overuse of HRT, we propose to conduct a diagnostic trial using multimodal MRI techniques to quantify the severity of these perimenopausal migraineurs who are susceptible to the decline of estrogen.

Methods

Perimenopausal women suffering from migraine will be recruited from the pain clinic of our hospital. Perimenopausal women not suffering from any kind of headache will be recruited from the local community. Clinical assessment and multi-modal MR imaging examination will be conducted. A follow up will be conducted once half year within 3 years. Pain behavior, neuropsychology scores, fMRI analysis combined with suitable statistical software will be used to reveal the potential association between these above traits and the susceptibility of migraine.

Discussion

Multi-modal imaging features of both healthy controls and perimenopausal women who are susceptible to estrogen decline will be acquired. Imaging features will include volumetric characteristics, white matter integrity, functional characteristics, topological properties, and perfusion properties. Clinical information, such as basic information, blood estrogen level, information of migraine, and a bunch of neurological scale will also be used for statistic assessment. This clinical trial would help to build an effective screen system for quantifying the severity of illness of those susceptible women during the perimenopausal period.

Trial registration

This study has already been registered at Clinical Trials. gov (ID: NCT02820974). Registration date: September 28th, 2014.

Migraines and perimenopause: helping women in midlife manage and treat migraine

Migraine is more common in women than men, with lifetime prevalence rates between 15 percent and 26 percent for women. The World Health Organization ranks migraine as 12th among all causes of years lived with disability in women. This article reviews diagnostic criteria for migraine with and without aura, the impact of fluctuating hormones in perimenopause on the experience of migraine and medication and nonmedication approaches to managing migraine.

Hormonal manipulation strategies in the management of menstrual migraine and other hormonally related headaches

Menstrual migraine and other hormonally related headaches are common in women. Falling estrogen levels or estrogen withdrawal after periods of sustained higher levels can trigger migraine. It makes sense to target this trigger for management of hormonally related headaches, particularly when nonhormonal strategies have been unsuccessful. Decision making regarding the use of hormonal contraception and menopausal hormone therapy is complex and commonly driven by other factors, but hormonal manipulation can potentially improve the course of migraine. Providers caring for migraineurs are appropriately concerned about stroke risk. Estrogen-containing hormonal contraceptives are relatively contraindicated for women who have migraine with aura. Postmenopausal hormone therapy is acceptable for women with a history of migraine. For these women, transdermal estradiol is recommended. Estrogen replacement is important for women who undergo an early menopause, whether natural or induced. Practical strategies for hormonal manipulation in the management of migraine and other hormonally related headaches are presented.

Health correlates and mode of administration of hormones--are there any differences between parenteral and oral estrogen preparations?

OBJECTIVES

To investigate use-associated differences between parental and oral hormone therapy (HT) users in reference to HT non-users regarding self-rated general health status, quality of life, health service utilization, and selected chronic diseases.

METHODS

All cases of last-week medicine use were recorded among 2248 women aged 40-79 who participated in the German Health Interview and Examination Survey 1997-1999. 89 current parenteral HT users and 322 oral HT users were identified. Health correlates were compared between the two groups in reference to HT non-users.

RESULTS

Oral HT users had a poorer current health status as well as an impaired health status compared to the year before, were less satisfied with their health and life in general, and showed a lower quality of life regarding 'body pain' and 'vitality' in comparison with hormone non-users (all p<.05). Parenteral HT users showed no significant difference compared with HT non-users and oral HT users, respectively, in these health correlates except for a less satisfaction with health found in comparison with HT non-users (p=.002). Prevalences of cerebral-cardiovascular diseases were not different among women using parenteral or oral HT use. Parenteral HT users visited the offices of general practitioner and gynecologists more frequently than oral HT users as well as hormone non-users (all p<.05).

CONCLUSIONS

Oral HT use is associated with a negative assessment for health well-being whereas parenteral HT use shows largely a neutral effect. Further designated studies could clarify whether the mode of hormone administration consistently affects health-related quality of life and whether the mode of hormone treatment influences the choice of outpatient facilities for surveillance of therapy.