The association of menstrual migraine with the premenstrual syndrome

Cumulative exposure to estrogen may increase the risk of migraine in women

BACKGROUND

Migraine is a common disorder, particularly affecting women during their reproductive years. This female preponderance has been linked to exposure to female sex hormones.

METHODS

We used self-reported data from women born in 1943-1965 enrolled in the Norwegian Women and Cancer Study to examine the differences between women with migraine and women without migraine in a prospective design with respect to both endogenous and exogenous female sex hormone exposure.

RESULTS

In total, 62,959 women were included in the study, of whom 24.8% reported previous migraine (n = 15,635). Using a Cox proportional hazards model, we found that higher age at menarche reduced the risk of migraine (hazards ratio (HR) = 0.96, 95% confidence interval (CI) = 0.95-0.98) and that oral contraceptive use and parity increased the risk of migraine (HR = 1.12, 95% CI = 1.06-1.18 and HR = 1.37, 95% CI = 1.29-1.46, respectively).

CONCLUSIONS

Older age at menarche appears to reduce migraine risk, whereas oral contraceptive use and having children appear to increase the risk. Further research is required to investigate the causality of these associations.

Comparing Perimenstrual and Nonperimenstrual Migraine Attacks Using an e-Diary

BACKGROUND AND OBJECTIVES

Endogenous and exogenous female sex hormones are considered important contributors to migraine pathophysiology. Previous studies have cautiously suggested that perimenstrual migraine attacks have a longer duration and are associated with higher disability compared to nonperimenstrual attacks, but they showed conflicting results on acute therapy efficacy, pain intensity, and associated symptoms. We compared perimenstrual and nonperimenstrual migraine attack characteristics and assessed premenstrual syndrome (PMS) in women with migraine.

METHODS

Women with migraine were invited to complete a headache e-diary. Characteristics of perimenstrual attacks and nonperimenstrual attacks were compared. The primary outcome was attack duration. Secondary outcomes were headache intensity, accompanying symptoms, acute medication intake, and pain coping. Mixed effects models were used to account for multiple attacks within patients. PMS was assessed in patients without hormonal contraceptives. Subgroup analyses were performed for women with menstrually related migraine (MRM) and nonmenstrually related migraine (non-MRM) and women with a natural menstrual cycle and women using hormonal contraceptives.

RESULTS

A representative group of 500 participants completed the e-diary for at least 1 month. Perimenstrual migraine attacks (n = 998) compared with nonperimenstrual attacks (n = 4097) were associated with longer duration (20.0 vs 16.1 hours, 95% confidence interval 0.2-0.4), higher recurrence risk (odds ratio [OR] 2.4 [2.0-2.9]), increased triptan intake (OR 1.2 [1.1-1.4]), higher headache intensity (OR 1.4 [1.2-1.7]), less pain coping (mean difference -0.2 [-0.3 to -0.1]), more pronounced photophobia (OR 1.3 [1.2-1.4]) and phonophobia (OR 1.2 [1.1-1.4]), and less aura (OR 0.8 [0.6-1.0]). In total, 396/500 women completed the diary for ≥3 consecutive menstrual cycles, of whom 56% (221/396) fulfilled MRM criteria. Differences in attack characteristics became more pronounced when focusing on women with MRM and women using hormonal contraceptives. Prevalence of PMS was not different for women with MRM compared to non-MRM (11% vs 15%).

DISCUSSION

The longer duration of perimenstrual migraine attacks in women (with MRM) is associated with higher recurrence risk and increased triptan use. This may increase the risk of medication overuse and emphasizes the need to develop female-specific prophylactic treatment.

Symptoms of premenstrual syndrome in female migraineurs with and without menstrual migraine

BACKGROUND

Menstrual migraine (MM) and premenstrual syndrome (PMS) are two conditions linked to specific phases of the menstrual cycle. The exact pathophysiological mechanisms are not fully understood, but both conditions are hypothesized to be triggered by female sex hormones. Co-occurrence of MM and PMS is controversial. The objective of this population-based study was to compare self-assessed symptoms of PMS in female migraineurs with and without MM. A total of 237 women from the general population who self-reported migraine in at least50% of their menstruations in a screening questionnaire were invited to a clinical interview and diagnosed by a neurologist according to the International Classification of Headache Disorders II (ICHD II), including the appendix criteria for MM. All women were asked to complete a self-administered form containing 11 questions about PMS-symptoms adapted from the Diagnostic and Statistical Manual of Mental Disorders. The number of PMS symptoms was compared among migraineurs with and without MM. In addition, each participant completed the Headache Impact test (HIT-6) and Migraine Disability Assessment Score (MIDAS).

FINDINGS

A total of 193 women returned a complete PMS questionnaire, of which 67 women were excluded from the analyses due to current use of hormonal contraception (n = 61) or because they did not fulfil the ICHD-criteria for migraine (n = 6). Among the remaining 126 migraineurs, 78 had MM and 48 non-menstrually related migraine. PMS symptoms were equally frequent in migraineurs with and without MM (5.4 vs. 5.9, p = 0.84). Women with MM reported more migraine days/month, longer lasting migraine attacks and higher HIT-6 scores than those without MM, but MIDAS scores were similar.

CONCLUSION

We did not find any difference in number of self-reported PMS-symptoms between migraineurs with and without MM.

Current Treatment Options: Headache Related to Menopause-Diagnosis and Management

PURPOSE OF REVIEW

Menopause is a life-changing event in numerous ways. Many women with migraine hold hope that the transition to the climacteric state will coincide with a cessation or improvement of migraine. This assumption is based mainly on common lay perceptions as well as assertions from many in the healthcare community. Unfortunately, evidence suggests this is far from the rule. Many women turn to a general practitioner or a headache specialist for prognosis and management. A natural instinct is to manipulate the offending agent, but in some cases, this approach backfires, or the concern for adverse events outweighs the desire for a therapeutic trial, and other strategies must be pursued. Our aim was to review the frequency and type of headache syndromes associated with menopause, to review the evidence for specific treatments for headache associated with menopause, and to provide management recommendations and prognostic guidance.

RECENT FINDINGS

We reviewed both clinic- and population-based studies assessing headache associated with menopause. Headache in menopause is less common than headache at earlier ages but can present a unique challenge. Migraine phenotype predominates, but presentations can vary or be due to secondary causes. Other headache types, such as tension-type headache (TTH) and cluster headache (CH) may also be linked to or altered by hormonal changes. There is a lack of well-defined diagnostic criteria for headache syndromes associated with menopause. Women with surgical menopause often experience a worse course of disease status than those with natural menopause. Hormonal replacement therapy (HRT) often results in worsening of migraine and carries potential for increased cardiovascular and ischemic stroke risk. Estrogen replacement therapy (ERT) in patients with migraine with aura (MA) may increase the risk of ischemic stroke; however, the effect is likely dose-dependent. Some medications used in the prophylaxis of migraine may be useful in ameliorating the vasomotor and mood effects of menopause, including venlafaxine, escitalopram, paroxetine, and gabapentin. Other non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga may also be helpful in reducing headache and/or vasomotor symptoms associated with menopause. The frequency and type of headache associated with menopause is variable, though migraine and TTH are most common. Women may experience a worsening, an improvement, or no change in headache during the menopausal transition. Treatment may be limited by vascular risks or other medical and psychiatric factors. We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga. If HRT is pursued, continuous (rather than cyclical) physiological doses should be used, transdermal route of administration is recommended, and the patient should be counseled on the potential for increased risk of adverse events (AEs). Concomitant use of a progestogen decreases the risk of endometrial hyperplasia with ERT. Biological mechanisms are incompletely understood, and there is a lack of consensus on how to define and classify headache in menopause. Further research to focus on pathophysiology and nuanced management is desired.

Migraine and reproductive life

Migraine is prevalent in women during the fertile age. Indeed, both neuroendocrine events related to reproductive stages (menarche, pregnancy, and menopause) and menstrual cyclicity and the use of exogenous sex hormones, such as hormonal contraception and replacement therapy, may cause significant changes in the clinical pattern of migraine. Menstrual migraine may be more severe, long-lasting, and refractory to both acute and prophylactic treatment and, therefore, requires tailored strategies. The use of headache diaries, which makes it possible to record prospectively the characteristics of every attack, is of paramount importance for evaluating the time pattern of headache and for identifying a clear link with menstrual cycle-related features. Estrogen variations are highly implicated in modulating the threshold to challenges by altering neuronal excitability, cerebral vasoactivity, pain sensitivity, and neuroendocrine axes throughout the menstrual cycle and not only at the time of menstruation. On the other hand, estrogen withdrawal may really constitute a triggering factor for migraine in women with peculiar characteristics of vulnerability with menstruation or following the discontinuation of exogenous estrogen, as happens with hormonal contraception during the fertile age or with hormone therapy at menopause. In addition, exogenous estrogen may contribute to the occurrence of neurological symptoms, such as aura. When aura occurs, hormonal treatment should be discontinued.

Transdermal hormonal therapy in perimenstrual migraine: why, when and how?

Experimental and clinical evidence is strongly in favor of a role for estrogens in migraine. It is clear that estrogen fluctuations represent trigger factors for the attacks, while the resolution of these fluctuations (menopause) may be associated to the remission or, conversely, to the worsening of the disease. However, the exact mechanisms and mediators underlying the effects of estrogens in migraine are largely unknown. The exact mechanisms and mediators underlying the effects of estrogens in migraine are largely unknown. In this review, we summarize clinical and preclinical data that are relevant for the role of estrogens in migraine and we discuss how estrogen modulation can be exploited positively to improve hormonal-related migraine.

Premenstrual syndrome and migraine

Premenstrual syndrome (PMS) includes a wide variety of physical, psychological, and cognitive symptoms that occur recurrently and cyclically during the luteal phase of the menstrual cycle and disappear soon after the onset of menstruation. Headache, often of migrainous type, is one of physical symptoms often reported in the diagnostic criteria for PMS. Menstrual migraine (MM) is a particular subtype of migraine occurring within the 2 days before and the 3 days after the onset of menses. According to this definition, therefore, some attacks of MM certainly occur in conjunction with the period of maximum exacerbation of PMS symptoms. The relationship between MM and PMS has been investigated through diary-based studies which have confirmed the possible correlation between these two conditions. In this paper we provide indications for the treatment of MM, making particular reference to those therapies that may be useful in the treatment of PMS symptoms. Even if triptans are the gold standard for the acute treatment, if symptomatic treatment is not sufficient one can resort to a short-term perimenstrual prophylaxis. Non-steroidal anti-inflammatory drugs have been demonstrated effective in MM prophylaxis. Among natural products there is some evidence of efficacy for magnesium, phytoestrogens, and ginkgolide B. Finally, also a combined oral contraceptive containing drospirenone, taken continuously for 168 days, has shown promising results.

Mid-cycle headaches and their relationship to different patterns of premenstrual stress symptoms

BACKGROUND

Recent research has shown that affective changes associated with the menstrual cycle may follow diverse patterns, including a classic premenstrual syndrome pattern, as well as the mirror opposite pattern, referred to as a mid-cycle pattern.

OBJECTIVE

Test for the presence of a mid-cycle pattern of headaches, in addition to a menstrual pattern and a noncyclic pattern; test for an association between experiencing a specific pattern of headaches and a specific (previously identified) pattern of depression/anxiety; and test for mean-level differences, across headache pattern groups, in average headache index and depression/anxiety scores (averaged across 2 menstrual cycles for each participant).

METHODS

A sample of 213 female university students completed daily questionnaires regarding symptoms of headaches and depression/anxiety for 2 menstrual cycles. Hierarchical linear modeling, polynomial multiple regression, analyses of variance, and chi-square analyses were used to test the hypotheses.

RESULTS

Confirmed the existence of a mid-cycle pattern of headaches (16%), in addition to a menstrual pattern (51%), and a noncyclic pattern of headaches (33%). Patterns of headaches and affective change were significantly associated (χ(2) = 21.33, P = .0003; 54% correspondence), as were the average headache index and depression/anxiety scores (r = .49; P < .0001). No significant mean-level differences were found between the headache pattern groups on the average headache index scores or depression/anxiety scores.

CONCLUSIONS

A significant number of women experience a mid-cycle pattern of headaches during the menstrual cycle. Moreover, women often, but not always, demonstrate the same pattern of headaches and depression/anxiety symptoms.

Migraine in women: the role of hormones and their impact on vascular diseases

Migraine is a predominantly female disorder. Menarche, menstruation, pregnancy, and menopause, and also the use of hormonal contraceptives and hormone replacement treatment may influence migraine occurrence. Migraine usually starts after menarche, occurs more frequently in the days just before or during menstruation, and ameliorates during pregnancy and menopause. Those variations are mediated by fluctuation of estrogen levels through their influence on cellular excitability or cerebral vasculature. Moreover, administration of exogenous hormones may cause worsening of migraine as may expose migrainous women to an increased risk of vascular disease. In fact, migraine with aura represents a risk factor for stroke, cardiac disease, and vascular mortality. Studies have shown that administration of combined oral contraceptives to migraineurs may further increase the risk for ischemic stroke. Consequently, in women suffering from migraine with aura caution should be deserved when prescribing combined oral contraceptives.

Neuroendocrine aspects of migraine in women

Migraine is a complex disabling disease influenced mainly by age and gender during the life span. Neuroendocrine events related to reproductive stages and to the menstrual cycle may cause significant change in the clinical pattern of migraine over time, as a consequence of failure in adaptation higher in women than in men. Indeed, the individual threshold of vulnerability to manifest migraine is modulated by hormonal fluctuations naturally occurring throughout the menstrual cycle and at the time of reproductive transitions. In the present short review, the role of endogenous estrogen at the level of brain circuitries which are involved in multiple cellular, neurochemical and neurophysiological processes associated with migraine will be summarized in the context of reproductive milestones. In addition, some clues to recognize hormonally sensitive women on the basis of their migraine history, i.e. onset, association with menstruation or premenstrual syndrome, course during pregnancy and menopause, will be discussed in order to expand the knowledge of reproductive endocrinology in the management of migraine in women.

Characterization of headaches in the premenstrual tension syndrome

OBJECTIVE: Characterization of headaches in premenstrual syndrome (PMS). Although headache is one of the symptoms for PMS, no details on this headache are given by the American College of Obstetrics and Gynecology (ACOG) criteria. METHOD: A group of 45 fertile age women presenting PMS were invited to complete a registration diary for headache and PMS symptoms for three consecutive months. The diary included details of each headache attack, allowing for classification according to the International Headache Society criteria (IHS-2004). RESULTS: Migraine without aura was the most common type of headache in PMS (n=27, 60%), followed by tension type headache (n=15, 30%). Only in two cases the type of headache varied among the observed months, and only in one case the diagnosis could not be concluded by the IHS-2004 criteria. CONCLUSION: Better clinical and therapeutic approach to headache in PMS can be achieved if the patient's type of headache could be properly characterized.

Menstrual migraine: a review of hormonal causes, prophylaxis and treatment

Migraine in some women is associated with changes in sex hormone levels. Many women suffer from increased frequency of migraine around the time of menses. Menstrual migraine (MM) may be more severe than migraine that occurs at other times of the cycle. The pathogenesis of MM is probably related to declining estrogen levels after exposure to high levels of the hormone for several days. The acute treatment of MM is similar to that of non-menstrually-related attacks. 5-HT(1B/1D) agonists (triptans), ergots, NSAIDs, or combination analgesics may be used, although the response to some drugs may not be as robust as that of non-menstrual attacks. Women who suffer from frequent or debilitating MM attacks may benefit from perimenstrual prophylaxis that can be either hormonal or non-hormonal.

Evaluation of an electronic diary as a diagnostic tool to study headache and premenstrual symptoms in migraineurs

OBJECTIVE

To evaluate an electronic diary as a tool to evaluate the occurrence and relationship of headaches and premenstrual syndrome (PMS) symptoms throughout the menstrual cycle in women with migraine.

BACKGROUND

Menstrually related headache and PMS significantly impact the quality of life of many women. The time relationship of these 2 menstrually related problems is not well understood and not well described.

METHODS

Twenty women with migraine experiencing regular menstrual cycles were enrolled in a prospective study designed to date- and time-stamp data, both self- and computer-prompted, headache and PMS symptoms, for 3 consecutive months. A previously validated PMS score was calculated by grading 23 PMS criteria on a scale of 0 to 3 (0 = no symptoms, 3 = severe symptoms).

RESULTS

The total number of data entries recorded was 2009, composed of 56 menstrual cycles in 20 migraineurs. Five hundred forty-four entries reported a current, prodromal, or previous headache. The mean daily occurrence of headache increased beginning on cycle day -5, peaked on days +1 to +5, and returned to baseline by day +7. Mean daily PMS scores ranged from 2.4 to 12. Mean daily PMS scores peaked on days -6 to +2 and returned to baseline by day +8.

CONCLUSIONS

An electronic diary may have potential as a diagnostic tool in studying headaches and PMS symptoms throughout the menstrual cycle. The occurrence of headache and PMS symptoms in migraineurs follows similar time courses.

Hormone-related headache: pathophysiology and treatment

Epidemiological data suggest a link between migraine and the female sex hormones. Indeed, it is known that estrogen affects various brain functions, including pain perception. The prevalence of migraine is similar in boys and girls before puberty, but is 3-fold higher in postpubertal females compared with males. Migraine attacks in women are more likely to occur in the perimenstrual period and occur exclusively so in some women. The acute treatment of menstrual migraine is similar to that of non-menstrually related attacks, but the response to treatment may be less favourable. Perimenstrual prophylaxis, with NSAIDs, triptans or estradiol, is effective in decreasing attack frequency and severity. The use of oral contraceptives (OCs) may change migraine frequency and severity. Since both migraine and hormonal contraceptive use are risk factors for ischaemic stroke, the use of OCs in women who experience migraine should be made only after consideration of the benefit-risk ratio. Migraine typically, but not invariably, improves during the last two trimesters of pregnancy, and may worsen in the postpartum period. When using drugs to treat migraine during pregnancy, potential risks to the mother and fetus should be considered. The prevalence of migraine decreases with advancing age and it improves in many, but not all, women after the menopause. However, in the perimenopausal period, migraine may worsen as a result of fluctuations in estrogen levels. Reducing the estrogen dose and changing the estrogen type or the route of administration of hormone replacement therapy (HRT) from oral to transdermal may reduce headache. Migraine is not a risk factor for stroke in postmenopausal women. When considering symptomatic HRT for postmenopausal migraneurs, the usual indications and contraindications should be applied. HRT may also exacerbate migraine.

Symptoms of Premenstrual Syndrome and Their Association With Migraine Headache

OBJECTIVES

To determine the association between the severity of premenstrual (PMS) symptoms and headache outcome measures during natural menstrual cycles and after medical oophorectomy.

BACKGROUND

Premenstrual syndrome may occur in 64% of those with pure menstrual migraine and 33% of those with menstrually related migraine. Few past studies have examined the relationship between the severity of PMS symptoms and migraine headache.

METHODS

Data were obtained from a 6.5-month randomized-controlled trial examining the role of medical oophorectomy in the prevention of migraine headache and later divided into two data sets for analysis purposes. The menstrual cycle data set was composed of data from three natural menstrual cycles obtained from 21 participants during lead-in and placebo run-in phases. Each menstrual cycle was subdivided into seven 3-day intervals based on urine hormone metabolites. The medical oophorectomy data set included data from a 2-month treatment period in which a medical oophorectomy was induced by gonadotropin-releasing hormone agonists (GnRHa) and participants were randomized to transdermal estradiol or a matching placebo (GnRHa/estradiol and GnRHa/placebo groups, respectively). All participants completed a daily diary recording the severity of PMS symptoms and headache outcome measures. The primary outcome measures were the PMS index (mean of the daily PMS severity scores) and the headache index (mean of the headache severity scores). Pearson correlation coefficients were used to assess the degree of association between the outcome measures.

RESULTS

Menstrual Cycle Data Set.-The PMS index was significantly correlated with the headache index during native menstrual cycles (correlation coefficient of 0.47; P < .05) and during all seven intervals of the menstrual cycle (correlation coefficients of 0.39 to 0.65; all P values < .05). Medical Oophorectomy Data Set.-Correlation coefficients between the PMS and headache indices were 0.58 and 0.47 for the GnRHa/estradiol (n = 9) and GnRHa/placebo groups, respectively (P-values of <.05).

CONCLUSIONS

Moderate correlations exist within female migraineurs between the severity of PMS symptoms and headache outcome measures throughout natural menstrual cycles as well as after medical oophorectomy. Our data would suggest that the presence and severity of headache might modulate PMS symptoms in female migraineurs.

Water deprivation: a new migraine precipitant

Fifty migraineurs were asked if insufficient fluid intake could provoke their migraine attacks. Twenty replied "yes," 7 were doubtfully positive, and 23 said "no." In addition 14 of 45 migraineurs at a meeting of the British Migraine association (UK) also recognized fluid deprivation as one of their migraine triggers. Thus a total of 34 of 95 migraineurs knew that dehydration could provoke their attacks, a precipitant not recognized by the medical profession. This indicates that we can add fluid deprivation to our list of migraine precipitants. It would be interesting to know the extent to which it applies in other climates. Further research is needed into the mechanism of this precipitant.

Menstrual migraine

Migraine is a common disorder that is disproportionately prevalent in women, especially during the reproductive years. Hormonal changes may play a role in the etiology of migraine, as many women note that their migraine attacks occur in temporal relationship with their menses. The Headache Classification Subcommittee of the International Headache Society has recently defined menstrual and menstrually related migraine. We review the most relevant and recent literature on menstrual migraine, with a special focus on pathophysiology and therapy. Although the pathogenesis of menstrual and menstrually related migraine is not well understood, estrogen withdrawal seems to play an important role as a trigger for menstrual migraine attacks. The therapeutic approach also may differ from the treatment of nonmenstrual migraine. Some patients do not require prophylaxis when they can abort their attacks effectively, whereas others may benefit from perimenstrual prophylaxis or standard migraine prophylaxis.

Menstrual migraine: A review of prophylactic therapies

Menstrual migraine is commonly encountered in women who are experiencing attacks of migraine without aura. It remains controversial whether attacks of menstrually associated migraine are more severe and have a longer duration than non-menstrually associated attacks. The pathogenesis of menstrual migraine is not understood completely, but it may be related to estrogen withdrawal or prostaglandin release. Preventative therapies may be considered in those who have failed abortive medications or have attacks lasting longer than 2 days. They can be administered short-term during the perimenstrual time period or continuously throughout the menstrual cycle. Short-term prophylactics should be tried first because menstrual migraines generally last for 1 to 4 days only. Continuous prophylactics may be considered in those with attacks refractory to short-term therapies.

Neuroendocrine response to the serotonin agonist M-chlorophenylpiperazine in women with menstrual status migrainosus

To assess the neuroendocrine correlates of menstrual status migrainosus (MSM) and menstrual migraine (MM), we evaluated the prolactin (PRL) and cortisol responses to the direct central serotoninergic (5-HT) agonist meta-chlorophenylpiperazine (m-CPP) administered orally (0.5 mg/kg) during the follicular (FP: +6, +8) and luteal phases (LP: -4, -6) of the same menstrual cycle. Ten women with MSM (migraine attacks occurring within 2 days of the onset of menstrual bleeding but lasting more than 72 h) and 9 women with MM (migraine occurring within 2 days of the onset of menstrual bleeding with a typical duration of attacks) were studied. Six healthy women served as controls. Blood samples were taken at times -30, 0 and every 30 min over 4 h. Statistical analysis was performed using MANOVA followed by Duncan's post hoc comparisons. We found that the PRL response to the m-CPP test was significantly blunted in MSM compared with MM and controls in both phases of the menstrual cycle (F = 4.6; p < 0.001). Indeed, the PRL area under the curve (AUC) after m-CPP was higher in both MM and controls compared with MSM (F = 12.7; p < 0.001). The m-CPP-induced cortisol response was absent in MSM compared with MM and controls in both FP and LP (F = 4.1; p < 0.001). On the other hand, the pattern of the plasma cortisol response to m-CPP was similar in MM and controls throughout the menstrual cycle. In addition, the basal plasma cortisol levels were significantly higher in MSM compared with controls (p < 0.001) and MM (p < 0.001) during FP, but not in LP, and progressively decreased over time. Thus, no significant effect of the menstrual cycle phase and diagnosis on the cortisol AUC was found, while a significant diagnosis effect (F = 25.6; p < 0.001) on %delta(max) plasma cortisol levels was evident and consistent with the lack of cortisol response to m-CPP in MSM during the FP and LP compared with MM and controls. A derangement in central 5-HT control of pituitary PRL, and even more so in cortisol release, is present in women with MSM, but not with MM, regardless of the phase of the menstrual cycle, suggesting the involvement of some 5-HT(1) and 5-HT(2) receptor subtypes in the occurrence of extremely severe migraine attacks triggered by menstruation.

Migraine prevalence during menopausal transition

BACKGROUND

The effect of menopausal transition on the frequency of migraine has never been the focus of a community-based study.

METHODS

A cross-sectional community-based survey was undertaken among Chinese women aged 40 to 54 years in Kinmen, Taiwan. Neurologists diagnosed migraine based on the 1988 International Headache Society classification criteria. Menstrual history including a past or current history of premenstrual syndrome was obtained. Serum levels of estradiol and follicle-stimulating hormone were measured.

RESULTS

The 1-year prevalence of migraine was 16.5% in the 1436 participants. Among the women who had not had hysterectomies and did not report symptoms of premenstrual syndrome, migraine prevalence did not vary according to menopausal status. In contrast, in women with self-reported premenstrual syndrome, menopausal status was a factor in migraine prevalence: the late perimenopausal group had the highest prevalence (31%) and the spontaneous menopausal group had the lowest (7%). Among all menopausal groups, women who had had hysterectomies reported the highest migraine prevalence (27%), with the highest occurring in those with premenstrual syndrome (44%). The presence of low estrogen (<50 pg/mL) and high follicle-stimulating hormone levels (>30 mIU/mL) was associated with lower migraine prevalence, even in the premenopausal and early perimenopausal women.

CONCLUSIONS

Our data supported the clinical impression that migraine prevalence increases before menopause and declines after spontaneous menopause. However, in this study, this trend occurred only in women with increased vulnerability to hormonal change, such as those with premenstrual syndrome. The presence of low estrogen and high follicle-stimulating hormone levels predicted lower migraine prevalence, whereas a history of hysterectomy was related to higher prevalence.

Hormonal factors in migraine: a population-based study of women aged 40 to 74 years

OBJECTIVE

This study investigated some of the relationships between migraine and hormonal factors.

METHODS

A neurologist clinically assessed 728 women aged 40 to 74 years attending a population-based mammography screening program. Headache criteria proposed by the International Headache Society were used. Data on hormonal factors were obtained by interview and questionnaire.

RESULTS

Twenty-one percent of women with migraine without aura and 4% of women with migraine with aura reported that they experienced >/=75% of their attacks within -2 to +3 days of the menstrual cycle. During pregnancy, women experienced less frequent or less intense attacks of migraine without aura and migraine with aura. A small but significant proportion (12%, P =.04) of women with migraine without aura also had premenstrual disorder. Associations between migraine and menarche, pregnancy, pregnancy-related complications, and menopausal complaints were generally weak and insignificant. Migraine with aura was not related to menopause. A crude odds ratio of 0.47 (95% confidence interval [CI] 0.24-0.86) indicated a decrease in risk for migraine without aura in postmenopausal women. However, after adjusting for differences in age and the use of hormonal replacement therapy, this association was not statistically significant. Time since menopause was a significant factor for migraine without aura in postmenopausal women.

CONCLUSION

Although many women with migraine reported a close relationship between their attacks and menses, and relief during pregnancy, the cross-sectional associations between migraine and menopause and menopausal complaints were insignificant.

Prevalence of menstrually related migraine and nonmigraine primary headache in female students of Belgrade University

OBJECTIVES

To determine prevalence and characteristics of menstrually related migraine and nonmigraine headache in female students of Belgrade University.

METHODS

A questionnaire was administered to female students during randomly selected classes of the Schools of Medicine and Pharmacy. Diagnoses were assigned according to the criteria of the International Headache Society and MacGregor's stricter definition of "menstrual" migraine.

RESULTS

Of 1943 female students (18 to 28 years old), 1298 (66.8%) had primary headaches. Among 1298 students with headache, 245 (12.6%) had migraine and 1053 (54.2%) had nonmigraine headache. The prevalence rates of migraine versus nonmigraine headache in relation to the menstrual cycle were: premenstrual, 0.9% versus 4.4%; menstrual, 1.5% versus 1.5%; menstrually associated, 6.1% versus 10.1%; menstrually unchanged, 2.7% versus 19.2%; and menstrually unrelated, 1.4% versus 18.9%. Female students with migraine had menstrually related attacks more frequently than students with nonmigraine headache (67.7% versus 29.5%). This difference was most prominent among students with menstrual migraine compared with students with menstrual nonmigraine headache (12.2% versus 2.7%). Exacerbation of migraine during menstruation was slightly more severe and more complex than exacerbation of nonmigraine headache. Female students with migraine versus nonmigraine headache did not differ significantly in age, age at onset of menarche, or age at onset of headache. Female students with migraine were significantly more likely to report a positive family history for migraine and menstrual migraine, severe attacks, reduced work activity, and aura.

CONCLUSION

The results obtained are in accord with the prevailing opinion that there is a relationship between migraine and female sex hormones, and suggest that women with nonmigraine headache are also susceptible to hormonal fluctuations.

Menstrual migraine

Migraine in women is influenced by hormonal changes throughout the life cycle: menarche, menstruation, oral contraceptive use, pregnancy, menopause, and hormonal replacement therapy (HRT). Based on clinical experience, the frequency of menstrual migraine has been reported to be as high as 60%-70%. Most women have increased headache and migraine attacks (usually without aura) at the time of menses. Attacks occurring only with menstruation, even if infrequent, are called true menstrual migraine. Attacks occurring both at menstruation and at other times of the month could be called "menstrually triggered migraine." Menstrual migraine occurs at the time of the greatest fluctuation in estrogen levels. Estrogen withdrawal is probably the trigger for migraine attacks in susceptible women. Drugs that are proven effective or commonly used for the acute treatment of menstrual migraine include nonsteroidal anti-inflammatory drugs (NSAIDs), dihydroergotamine, the triptans, and the combination of aspirin, acetaminophen, and caffeine. The goal of standard continuous preventive therapy is to reduce the frequency, duration, and intensity of attacks. Preventive therapy may eliminate all headaches except those associated with menses. Women already using prophylactic medication who continue to have menstrual migraine can increase the dose of their medication prior to their menses. Women who do not use preventive medicine or have migraine exclusively with their menses can be treated perimenstrually with short-term prophylaxis. If severe menstrual migraine cannot be controlled by acute and preventive treatment, hormonal therapy may be indicated.

Treatment of menstrual migraine

Because of its pathophysiological and clinical peculiarities, true menstrual migraine (MM) (i.e. migraine starting exclusively between the days immediately before and immediately after the first day of the menstrual cycle) requires an ad hoc management different from that of other migraines. The paucity of well-conducted, controlled clinical trials and the lack of a universally accepted definition of MM have meant that the treatment of MM is still largely empirical. In our clinical practice, we adopt a sequential therapeutic approach, including the following steps: (i) acute attack drugs (sumatriptan, ergot derivatives, NSAIDs); (ii) intermittent prophylaxis with ergot derivatives or NSAIDs; (iii) oestrogen supplementation with percutaneous or transdermal oestradiol (100 microg patches); (iv) antioestrogen agents (danazol, tamoxifen).

A clinical review of the adaptive role of vasopressin in migraine

Vasopressin is a naturally available neuropeptide that subserves important vasomotor, antinociceptive, behavior control, fluid and electrolyte balance, platelet aggregation and blood coagulation functions. This review focuses on the clinical phenomena of migraine that are likely to influence vasopressin bioavailability or efficacy as well as the modulating influence of vasopressin itself. As part of a complex homeostatic adjustment to stress and pain, the intricacies of vasopressin metabolism may have particular relevance to the pathophysiology of migraine.

"Menstrual" migraine: towards a definition

"Menstrual" migraine, a term misused by both patients and doctors, lacks precise definition. This dissertation critically reviews papers on the subject and examines the problem from a clinical perspective. A definition is proposed that the term "menstrual" migraine should be restricted to attacks exclusively starting on or between day 1 +/- 2 days of the menstrual cycle; the woman should be free from attacks at all other times of the cycle. This definition, unlike many used previously, links to a specific mechanism; the timing is consistent with oestrogen withdrawal. If this is correct, "oestrogen withdrawal" migraine may be a better term. Future studies, necessary to support or refute these proposals, are suggested.

Changes of neuroendocrine axes in patients with menstrual migraine

Menstrual migraine (MM) is a menstrually related disorder (MRD) characterized by several symptoms in common with premenstrual syndrome (PMS). It has been hypothesized that in both MM and PMS hormonal cyclicity could change the balance of neurotransmitters and neuromodulators like monoamine and opioid. In this article we analyze all the data collected by our group on the central opioid tonus and the adrenergic and serotonergic systems in patients affected by menstrual migraine.

Menstrual migraine is not pathogenetically related to premenstrual syndrome

Facchinetti and colleagues present epidemiological evidence regarding comorbidity between menstrual migraine and premenstrual syndrome, and suggest that premenstural symptoms should be incorporated in the diagnostic criteria for menstrual migraine (1). The crux of the matter, however, should be the concern regarding the nature or biological significance of the common neuroendocrine link of transient and cyclic failure of endogenous opioid activity in both premenstrual syndrome and menstrual migraine patients. Is this a primary event of pathogenetic importance (which would merit inclusion in the definition) or the concomitant side effect of a carefully orchestrated adaptive mechanism?