Migraine in women

Reversion of chronic to episodic migraine in working age and botulinum toxin-resistant patients treated with fremanezumab: A real-life study

OBJECTIVES

The objectives of this real-life study were to analyze the reversion of chronic migraine (CM) to episodic migraine (EM) with fremanezumab, evaluate its benefit on the symptomatology, and determine the influence of possible clinical features on the reversion.

BACKGROUND

The clinical manifestations of CM have a high impact on the quality of life of patients, and monoclonal antibodies such as fremanezumab are used as prophylactic treatment.

METHODS

Diagnosed CM patients treated for at least 3 months with monthly fremanezumab were interviewed. The data to assess efficacy were before treatment and at the time of the interview: monthly headache days (MHDs), daily headache hours (DHHs), monthly symptomatic medication days (MSMDs), percentage of patients with symptomatic medication overuse (SMO), and pain intensity with the numerical rating scale (NRS) score. Possible predictors of reversion were analyzed: percentage of patients treated for at least 12 months, hypertension, diabetes mellitus, depression, anxiety, symptomatic control with non-steroidal anti-inflammatory drugs (NSAIDs), triptans or both, and amitriptyline prophylaxis.

RESULTS

A total of 54 patients were included, of whom 40 (74.1%) were converters to EM. There were significant improvements in converters compared to pre-treatment in MHDs (28.0 vs. 5.0 days), as well as on the variables DHHs, MSMDs, and SMO. The percentage of erenumab failures was significantly higher in non-converters than in converters, as was the percentage of patients with anxiety.

CONCLUSIONS

High reversion from CM to EM was achieved with fremanezumab and notable symptomatological improvement, establishing previous failure to erenumab and anxiety as possible detrimental factors for reversion.

Use of Pharmacological and Non-Pharmacological Strategies by Community-Dwelling Adults to Manage Migraine: A Systematic Review

Migraine is a prevalent disease associated with high levels of disability and is often underdiagnosed and undertreated. This systematic literature review aimed to identify the types of pharmacological and non-pharmacological strategies that community-dwelling adults report using to manage migraine. A systematic literature review of relevant databases, grey literature, websites, and journals was conducted from 1 January 1989 to 21 December 2021. Study selection, data extraction, and risk of bias assessment were completed independently by multiple reviewers. Data were extracted on migraine management strategies and categorized as opioid and non-opioid medications and medical, physical, psychological, or self-initiated strategies. A total of 20 studies were included. The sample sizes ranged from 138 to 46,941, with a mean age of 34.7 to 79.9 years. The data were typically collected using self-administered questionnaires (nine studies), interviews (five studies), online surveys (three studies), paper-based surveys (two studies), and a retrospective database (one study). Community-dwelling adults with migraine reported they primarily used medications, specifically triptans (range 9-73%) and non-steroidal anti-inflammatory drugs (NSAIDs) (range 13-85%) to manage migraine. Except for medical strategies, the use of other non-pharmacological strategies was low. Common non-pharmacological strategies included consulting physicians (range 14-79%) and heat or cold therapy (35%).

Migraine, Brain Glucose Metabolism and the "Neuroenergetic" Hypothesis: A Scoping Review

Increasing evidence suggests that migraine may be the result of an impaired brain glucose metabolism. Several studies have reported brain mitochondrial dysfunction, impaired brain glucose metabolism and gray matter volume reduction in specific brain areas of migraineurs. Furthermore, peripheral insulin resistance, a condition demonstrated in several studies, may extend to the brain, leading to brain insulin resistance. This condition has been proven to downregulate insulin receptors, both in astrocytes and neurons, triggering a reduction in glucose uptake and glycogen synthesis, mainly during high metabolic demand. This scoping review examines the clinical, epidemiologic and pathophysiologic data supporting the hypothesis that abnormalities in brain glucose metabolism may generate a mismatch between the brain's energy reserve and metabolic expenditure, triggering migraine attacks. Moreover, alteration in glucose homeostasis could generate a chronic brain energy deficit promoting migraine chronification. Lastly, insulin resistance may link migraine with its comorbidities, like obesity, depression, cognitive impairment and cerebrovascular diseases. PERSPECTIVE: Although additional experimental studies are needed to support this novel "neuroenergetic" hypothesis, brain insulin resistance in migraineurs may unravel the pathophysiological mechanisms of the disease, explaining the migraine chronification and connecting migraine with comorbidities. Therefore, this hypothesis could elucidate novel potential approaches for migraine treatment.

Migraine: A Review on Its History, Global Epidemiology, Risk Factors, and Comorbidities

Migraine affects more than one billion individuals each year across the world, and is one of the most common neurologic disorders, with a high prevalence and morbidity, especially among young adults and females. Migraine is associated with a wide range of comorbidities, which range from stress and sleep disturbances to suicide. The complex and largely unclear mechanisms of migraine development have resulted in the proposal of various social and biological risk factors, such as hormonal imbalances, genetic and epigenetic influences, as well as cardiovascular, neurological, and autoimmune diseases. This review presents a comprehensive review of the most up-to-date literature on the epidemiology, and risk factors, as well as highlighting the gaps in our knowledge.

Is there any association between migraine headache and polycystic ovary syndrome (PCOS)? A review article

BACKGROUND

Polycystic ovary syndrome (PCOS) and migraine headaches are considered to be common health problems that may share some risk factors. This study aimed to discuss the possible association between migraine headache and polycystic ovary syndrome.

METHODS AND RESULTS

In this narrative review, PubMed, Scopus, Web of Science, and Google Scholar were systematically searched for retrieving and summarizing published studies up to January 2021 to explore the possible interplay between migraine headache and PCOS. We discuss the possible pathways that may explain the association between migraine headaches and PCOS signs/symptoms and complications. While genetic factors have profound effects on the pathogenesis of migraine headaches, sex hormones, including estrogen and progesterone may also play an important role in inducing migraine headaches. Some disorders, such as sleep apnea, amenorrhea, and vascular disease that are more likely to occur in women with PCOS, may cause or exacerbate migraine headaches in women with PCOS.

CONCLUSIONS

Future comprehensive studies are needed to investigate the exact underlining mechanisms related to the association between PCOS and migraine headaches.

Predictors of treatment response to pharmacotherapy in patients with persistent postural-perceptual dizziness

The study aimed to identify the predictors of response to selective serotonin reuptake inhibitors (SSRIs) for 12 weeks in patients with persistent postural-perceptual dizziness (PPPD). Short-term treatment responses were studied in 197 outpatients [127 (64.5%) women, mean age ± SD = 51.7 ± 15.9] diagnosed with PPPD. Clinical and self-rated assessments were analyzed at the baseline and at the end of pharmacotherapy for 12 weeks. Multivariable logistic regression analysis was used to determine the following variables as the potential predictors of treatment response as measured by scoring in clinical global impression-improvement scale (CGI-I) scores: age, sex, comorbidity, baseline CGI-S score, Beck Depression Inventory-II score, State-Trait Anxiety Inventory score, Dizziness Handicap Inventory score at the baseline, and prescribed doses of antidepressants or benzodiazepines. The overall response rate to pharmacotherapy was 65.0% (128/197). Female sex and greater disease severity at the baseline (higher CGI-S score) were associated with a better response to the pharmacotherapy. Subgroup analyses by sex identified younger age and lower anxiety as the indicators for better outcomes in men, and absence of comorbidities in women. During the initial assessment, the severity of PPPD was associated with depressive symptoms and subjective functional handicap due to dizziness. The response to pharmacotherapy is favorable in PPPD. Sex, age and initial disease severity are the predictors of the response to SSRIs in patients with PPPD.

Integrating Pathophysiology in Migraine: Role of the Gut Microbiome and Melatonin

BACKGROUND

The pathoetiology and pathophysiology of migraine are widely accepted as unknown.

METHODS

The current article reviews the wide array of data associated with the biological underpinnings of migraine and provides a framework that integrates previously disparate bodies of data.

RESULTS

The importance of alterations in stress- and pro-inflammatory cytokine- induced gut dysbiosis, especially butyrate production, are highlighted. This is linked to a decrease in the availability of melatonin, and a relative increase in the N-acetylserotonin/melatonin ratio, which has consequences for the heightened glutamatergic excitatory transmission in migraine. It is proposed that suboptimal mitochondria functioning and metabolic regulation drive alterations in astrocytes and satellite glial cells that underpin the vasoregulatory and nociceptive changes in migraine.

CONCLUSION

This provides a framework not only for classical migraine associated factors, such as calcitonin-gene related peptide and serotonin, but also for wider factors in the developmental pathoetiology of migraine. A number of future research and treatment implications arise, including the clinical utilization of sodium butyrate and melatonin in the management of migraine.

Association of endothelial nitric oxide synthase (NOS3) gene polymorphisms with primary open-angle glaucoma in a Saudi cohort

Aim

To investigate the association of endothelial nitric oxide synthase (NOS3) gene polymorphisms in patients with primary open-angle glaucoma (POAG) of Saudi origin.

Methods

This case-control study included 173 patients with POAG (94 men and 79 women) and 171 controls (98 men and 73 women). Genotyping of rs2070744 (T-786C) and rs1799983 (G894T) variants of the NOS3 gene was performed using TaqMan^® assay.

Results

Rs1799983 genotypes showed a significant association with POAG but did not survive Bonferroni correction (p_correction = 0.01). The minor ‘T’ allele was significantly associated with the risk of POAG among men (p = 0.025, odds ratio (OR) = 1.77, 95% confidence interval (CI) = 1.07–2.94). Likewise, the genotypes were significantly associated with POAG among men in dominant (p = 0.030, OR = 1.92, 95% CI = 1.06–3.48) and log-additive models (p = 0.022, OR = 1.82, 95% CI = 1.08–3.07), and after adjustment for age and smoking. Genotype and allele frequencies of rs2070744 were not significantly different between POAG cases and controls, and after sex stratification. CG haplotype was significantly protective (p = 0.011, OR = 0.52, 95% CI = 0.32–0.87) and CT haplotype conferred significantly increased risk of POAG (p = 0.016, OR = 2.60, 95% CI = 1.16–5.82) among men. Rs1799983 showed trend (p = 0.054) towards risk of POAG independent of age, gender, smoking, and rs2070744 polymorphism in logistic regression analysis. Both the polymorphisms showed no association with POAG phenotypes such as intraocular pressure and cup/disc ratio.

Conclusion

Our results suggest that the polymorphism rs1799983 and the haplotypes of rs20707440 and rs1799983 in the NOS3 gene may significantly modulate the risk of POAG in Saudi’s, particularly among men. Further larger studies are needed to confirm these findings.

Women and Migraine: the Role of Hormones

PURPOSE OF REVIEW

Migraine is a debilitating disease, that is encountered in countless medical offices every day and since it is highly prevalent in women, it is imperative to have a clear understanding of how to manage migraine. There is a growing body of evidence regarding the patterns we see in women throughout their life cycle and how we approach migraine diagnosis and treatment at those times.

RECENT FINDINGS

New guidelines regarding safety of medication during pregnancy and lactation are being utilized to help guide management decisions in female migraineurs. There is also new data surrounding the risk of stroke in individuals who suffer from migraine with aura. This article seeks to provide an overview of a woman's migraine throughout her lifetime, the impact of hormones and an approach to management.

Prostaglandin E2-mediated upregulation of neuroexcitation and persistent tetrodotoxin-resistant Na(+) currents in Ah-type trigeminal ganglion neurons isolated from adult female rats

Prostaglandin-E2 (PGE2) is a very important inflammatory mediator and PGE2-mediated neuroexcitation in sex-specific distribution of Ah-type trigeminal ganglion neurons (TGNs) isolated from adult female rats is not fully addressed. The whole-cell patch-clamp experiment was performed to verify the effects of PGE2, forskolin, and GPR30-selective agonist (G-1) on action potential (AP) and tetrodotoxin-resistant (TTX-R) Na(+) currents in identified Ah-type TGNs. The results showed that the firing frequency was increased in Ah- and C-types by PGE2, which was simulated by forskolin and inhibited by Rp-cyclic adenosine monophosphate (cAMP), while G-1 mimicked this effect only in Ah-types, which was abolished by GPR30-selective antagonist (G-15). Although the amplitude of AP was increased in Ah- and C-types, increased maximal upstroke velocity was confirmed only in Ah-types, suggesting distinct alternations in current density and/or voltage-dependent property of Na(+) channels. With 1.0 μM PGE2, TTX-R Na(+) currents were upregulated without changing the current-voltage relationship and voltage-dependent activation in C-types, however, the TTX-R Na(+) current was augmented in Ah-types, peaked voltage and the voltage-dependent activation were both shifted toward hyperpolarized direction with faster slope. Intriguingly, the low-threshold persistent TTX-R component was activated from -60 mV and increased almost double at -30 mV compared with ∼30-40% increment of TTX-R component being activated at ∼-10 mV. Additionally, the change in TTX-R component of Ah-types was equivalent well with that in C-type TGNs. Taken these data together, we conclude that PGE2 modulates the neuroexcitation via cAMP-mediated upregulation of TTX-R Na(+) currents in both cell-types with hormone-dependent feature, especially persistent TTX-R Na(+) currents in sex-specific distribution of myelinated Ah-type TGNs.

Migraine and Hormones

This article discusses the role that hormones play in adolescent girls and young women with headaches, which are very common in adolescent girls, in particular, migraine. In many cases, migraine onset may occur shortly around the time of menarche, prevalence of recurrent migraine in this population approaches 15%, and typically the symptoms continue through adulthood. Hormonal changes associated with puberty and the menstrual cycle may significantly influence migraine in young women. This article reviews the following topics: management of menstrually related headaches, changes in ovarian hormones and their relationship to migraine, and oral contraceptives and pregnancy effects on migraine.

Migraine in menopausal women: a systematic review

Evidence suggests that migraine activity is influenced by hormonal factors, and particularly by estrogen levels, but relatively few studies have investigated the prevalence and characteristics of migraine according to the menopausal status. Overall, population-based studies have shown an improvement of migraine after menopause, with a possible increase in perimenopause. On the contrary, the studies performed on patients referring to headache centers have shown no improvement or even worsening of migraine. Menopause etiology may play a role in migraine evolution during the menopausal period, with migraine improvement more likely occurring after spontaneous rather than after surgical menopause. Postmenopausal hormone replacement therapy has been found to be associated with migraine worsening in observational population-based studies. The effects of several therapeutic regimens on migraine has also been investigated, leading to nonconclusive results. To date, no specific preventive measures are recommended for menopausal women with migraine. There is a need for further research in order to clarify the relationship between migraine and hormonal changes in women, and to quantify the real burden of migraine after the menopause. Hormonal manipulation for the treatment of refractory postmenopausal migraine is still a matter of debate.

Gender differences in neurologic emergencies part I: a consensus summary and research agenda on cerebrovascular disease

Cerebrovascular neurologic emergencies including ischemic and hemorrhagic stroke, subarachnoid hemorrhage (SAH), and migraine are leading causes of death and disability that are frequently diagnosed and treated in the emergency department (ED). Although sex and gender differences in neurologic emergencies are beginning to become clearer, there are many unanswered questions about how emergency physicians should incorporate sex and gender into their research initiatives, patient evaluations, and overall management plans for these conditions. After evaluating the existing gaps in the literature, a core group of ED researchers developed a draft of future research priorities. Participants in the 2014 Academic Emergency Medicine consensus conference neurologic emergencies working group then discussed and approved the recommended research agenda using a standardized nominal group technique. Recommendations for future research on the role of sex and gender in the diagnosis, treatment, and outcomes pertinent to ED providers are described for each of three diagnoses: stroke, SAH, and migraine. Recommended future research also includes investigation of the biologic and pathophysiologic differences between men and women with neurologic emergencies as they pertain to ED diagnoses and treatments.

Myelinated Ah-type trigeminal ganglion neurons in female rats: neuroexcitability, chemosensitivity to histamine, and potential clinical impact

Migraine is a chronic neurological disorder characterized by recurrent moderate-to-severe headaches often associated with numerous autonomic nervous system symptoms, and it is more prevalent in women. To fully understand the underlying mechanism, standard electrophysiology was performed with trigeminal ganglion neurons (TGNs) isolated from adult rats of both genders using the whole-cell patch clamp technique to test the distribution, neuroexcitability, and chemosensitivity to histamine. In addition to traditionally classified A- and C-type TGNs, myelinated Ah-type TGNs were also observed in females. The electrophysiological features showed low firing threshold and the capability to fire repetitively upon stimulation. Ah-type neurons also functionally expressed persistent TTX-R Na(+) channels with more hyperpolarized activating voltage. Iberiotoxin and NS11021 significantly altered the discharge profiles of Ah-type TGNs. Finally, Ah-type TGNs showed a more potent reaction to histamine, with relatively larger inward currents and membrane depolarization compared with C-types. These data provide evidence of the gender-specific distribution of myelinated Ah-type TGNs in adult female rats, characterized by a low threshold and high frequency of firing that are at least partially attributable to persistent TTX-R Na(+) and BK-KCa channel expression and potent chemosensitivity to histamine, suggesting that Ah-type TGNs may play a key role in gender differences in migraine.

Frovatriptan vs. other triptans for the acute treatment of oral contraceptive-induced menstrual migraine: pooled analysis of three double-blind, randomized, crossover, multicenter studies

Oral contraceptive-induced menstrual migraine (OCMM) is a particularly severe form of migraine triggered by the cyclic hormone withdrawal. To review the efficacy of frovatriptan vs. other triptans, in the acute treatment of OCMM through a pooled analysis of three individual randomized Italian studies. With or without aura migraineurs were randomized to frovatriptan 2.5 mg or rizatriptan 10 mg (study 1), frovatriptan 2.5 mg or zolmitriptan 2.5 mg (study 2), frovatriptan 2.5 mg or almotriptan 12.5 mg (study 3). All studies had a multicenter, randomized, double-blind, crossover design. After treating 1-3 episodes of migraine in 3 months with the first treatment, patients switched to the other treatment for the next 3 months. In this analysis, the subset of 35 of the 280 women of the intention-to-treat population taking combined oral contraceptives and experiencing a migraine attack during the withdrawal phase, were analyzed. The proportion of pain free and pain relief at 2 h were 25 and 51 % with frovatriptan and 28 and 48 % with comparators (p = NS). At 24 h, 71 and 83 % of frovatriptan-treated patients and 60 and 76 % of comparator-treated patients were pain free (p < 0.05 between treatments) and had pain relief (p = NS), respectively. Relapse at 24 and 48 h was significantly (p < 0.05) lower with frovatriptan (17 and 21 %) than with the comparators (27 and 31 %). Our results suggest that, due to its sustained antimigraine effect, frovatriptan may be particularly suitable for the management of OCMM than other triptans.

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.

Association of polymorphisms of endothelial nitric oxide synthase (eNOS) gene with the risk of primary open angle glaucoma in a Brazilian population

The present study aimed to investigate the association of endothelial nitric oxide synthase (eNOS) gene polymorphisms with primary open angle glaucoma (POAG). We conducted a case-control study that included 90 patients with POAG and 127 healthy controls whose blood samples were genotyped for the functional polymorphisms T-786C and Glu298Asp of the eNOS gene by Taqman fluorescent allelic discrimination assay. The T-786C polymorphism was significantly associated as a risk factor for POAG among women (OR: 2.28; 95% CI: 1.11 to 4.70, p=0.024) and marginally associated to the risk of POAG in the patients ≥52 years of age at diagnosis (OR: 2.11; 95% CI: 0.98 to 4.55, p=0,055). However, these results was not confirmed after adjustments for gender, age, self-declared skin color, tobacco smoking and eNOS genotypes by multivariate logistic regression model (OR: 2.08; 95% CI: 0.87 to 5.01, p=0.101 and OR: 2.20; 95% CI: 0.95 to 5.12, p=0.067, respectively). The haplotype CG of T-786C and Glu298Asp showed a borderline association with risk of POAG in the overall analysis (OR: 1.76; 95% CI: 0.98 to 3.14, p=0.055) and among women (OR: 2.02; 95% CI: 0.98 to 4.16, p=0.052). Furthermore, the CG haplotype was significantly associated with the development of POAG for the age at diagnosis group ≥52 years (OR: 3.48; 95% CI: 1.54 to 7.84, p=0.002).We suggested that haplotypes of the polymorphisms T-786C and Glu298Asp of eNOS may interact with gender and age in modulating the risk of POAG.

Pure menstrual migraine with sensory aura: a case report

Hormonal changes related to the menstrual cycle have a great impact on migraines in women. Menstrual migraine attacks are almost invariably without aura. Categorizing migraines into menstrual or non-menstrual types is one way to stratify migraines without aura according to the appendix criteria of the International Classification of Headache Disorders. We report a peri-menopausal woman whose sensory aura exclusively heralded menstrual migraine. A 51-year-old woman had suffered from monthly episodic headaches since the age of 46. Before a headache, and within 1 h on the first day of her menstruation, she always experienced numbness in her entire left upper limb. After the sensory aura, migrainous headaches occurred with nausea and photophobia. In the postmenopausal period, she no longer had sensory aura, and her headache pattern changed and became less severe. Her physical and neurologic exams as well as electroencephalography, brain magnetic resonance imaging, and conventional angiography were all normal. She fulfilled the diagnosis of pure menstrual migraine with typical sensory aura. To our knowledge, this is the first formal case report of pure menstrual migraine with aura.

[Predictors of chronic pain following surgery. What do we know?]

Chronic postoperative pain is known to be a significant clinical and economic problem. The estimated mean incidence is high and varies between 10 and 50%, with variations mostly related to procedure-specific conditions. High-risk types of surgeries are e.g. thoracotomy, breast or inguinal hernia surgery and amputations. Although there is increasing knowledge about the incidence of chronic postoperative pain after certain types of surgical procedures, there are only limited data related to the mechanisms and pathophysiology leading to chronic pain after surgery. Neuropathic pain components have been discussed, especially following operations with a high incidence of nerve damage (for example axillary lymphadenectomy). Besides surgical factors it seems that there are a number of other factors which likely increase the risk of chronic postoperative pain. These predictors for the development of chronic postoperative pain are multiple and include individual genetic factors, age and sex of the individual patient, preoperative chronic pain, psychosocial factors, neurophysiological factors, intraoperative nerve and muscle damage, postoperative complications and acute pain in the early postoperative period. Quantitative sensory testing including tests of inhibitory circuits like DNIC might help to predict the risk of individual patients even before surgery has started. The perioperative identification of patients who are at high risk for developing chronic pain after surgery is therefore a major goal for the future. This may help to develop preventive treatment strategies and avoid treatments with side effects for patients who are not at risk for developing chronic pain after surgery. Due to a lack of appropriate data for sufficient preventive approaches an effective postoperative acute pain management and a nerve-conserving surgical technique are the major keys in the prophylaxis of chronic postoperative pain.

Headaches and hormones

It is clear that hormones play an important role in modulating and exacerbating headaches. From an epidemiologic standpoint, we know that before puberty, incidence of new headache is similar for boys and girls. By age 18, however, most new cases of migraine occur in young women. The role of sex hormones in headache is described in the context of pubertal development. Obesity and Pseudotumor also impact headache through hormonal influences. Menstrual migraine will often present in the teenage years. Oral contraceptives may worsen or ameliorate headache. This article will introduce these concepts and help the reader become familiar with the role of hormones in headache.

Endothelial nitric oxide synthase gene variants and primary open-angle glaucoma: interactions with sex and postmenopausal hormone use

PURPOSE

To evaluate the association between the nitric oxide synthase gene (NOS3) variants and primary open-angle glaucoma (POAG).

METHODS

Two functional single-nucleotide polymorphisms (SNPs) (T-786C: rs2070744; Glu298Asp: rs1799983) and three tagging SNPs (rs7830, rs3918188, and rs1800779) were evaluated in a nested case-control study from the Nurses' Health Study (1980-2002) and the Health Professionals' Follow-up Study (1986-2002). Participants were aged >or=40 years and Caucasian. Included were 527 incident cases and 1543 controls, matched by cohort, age, and eye examination at the matched cases' diagnosis dates. Cohort-specific relative risks (RR) were estimated by using multivariable conditional logistic regression and were pooled with meta-analysis.

RESULTS

No NOS3 polymorphism was significantly associated with overall POAG. For high-tension POAG (HTPOAG), rs3918188 was significantly inversely associated among the women (AA versus CC genotype: RR = 0.48; 95% CI, 0.28-0.82) but not among the men (P-heterogeneity by sex = 0.02). The minor alleles of T -786C and rs1800779 showed positive association with high-tension POAG (P-trend < 0.02) in the women only, but P-heterogeneity was not significant. In the women, four of the five NOS3 SNPs showed significant interactions with postmenopausal hormone (PMH) use in relation to HTPOAG: for example, among the women with the TT genotype in T -786C, PMH use was inversely associated (RR = 0.41; 95% CI, 0.22-0.76), but among carriers of the minor allele, use of PMH was not associated.

CONCLUSIONS

Interactions were observed between NOS3 SNPs and female sex and postmenopausal hormone use in the women in relation to HTPOAG. These findings should be confirmed in different racial/ethnic groups.

Hormonal management of migraine at menopause

In this review, we underline the importance of linking migraine to reproductive stages for optimal management of such a common disease across the lifespan of women. Menopause has a variable effect on migraine depending on individual vulnerability to neuroendocrine changes induced by estrogen fluctuations and on the length of menopausal transition. Indeed, an association between estrogen 'milieu' and attacks of migraine is strongly supported by several lines of evidence. During the perimenopause, it is likely to observe a worsening of migraine, and a tailored hormonal replacement therapy (HRT) to minimize estrogen/progesterone imbalance may be effective. In the natural menopause, women experience a more favourable course of migraine in comparison with those who have surgical menopause. When severe climacteric symptoms are present, postmenopausal women may be treated with continuous HRT. Even tibolone may be useful when analgesic overuse is documented. However, the transdermal route of oestradiol administration in the lowest effective dose should be preferred to avoid potential vascular risk.