Risks and benefits of hormone replacement therapy

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.

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.

Different effects of tibolone and low-dose EPT in the management of postmenopausal women with primary headaches

OBJECTIVE

The present randomized prospective study aimed to compare the effect of tibolone (T) with conventional low-dose estrogen-progestogen therapy (EPT) administered in a combined continuous regimen on the course of primary headaches in postmenopausal women requesting hormone therapy (HT) for climacteric complaints.

DESIGN

Forty women presenting for clinical evaluation of headache (migraine without aura and episodic tension-type headache) were enrolled. The observational period lasted 7 months during which women kept a diary of the clinical characteristics of headache attacks and analgesic use. Climacteric symptoms and both anxiety and depression were also measured. After a 1-month run-in period, women received two different HT regimens: 1 mg 17beta-estradiol + 0.5 mg norethisterone acetate (EPT) or 2.5 mg T. Follow-up evaluations were planned after 3 and 6 months of treatment.

RESULTS

Although T did not affect the number of days with migraine without aura, it significantly reduced the number of hours during which pain intensity prohibited daily activities (P < 0.001) and the number of analgesics (P < 0.001) after 3 months. Conventional low-dose EPT administered in a combined continuous regimen was confirmed to have a mild, but negative, effect on the course of migraine without aura by increasing the number of days with head pain (P < 0.001) and the number of analgesics (P < 0.001). Interestingly, both treatments were effective in the management of episodic tension-type headache, significantly reducing the number of days with head pain, severity, and analgesic consumption.

CONCLUSIONS

In postmenopausal headache sufferers, analgesics are more effective in alleviating severe head pain when women are treated with T in comparison with low-dose EPT for climacteric complaints.

Is bio-identical hormone therapy fact or fairy tale?

Bio-identical hormone replacement therapy (BHRT) is becoming more popular among women, and providers should have adequate knowledge regarding this treatment. This article reviews traditional hormone replacement therapy, BHRT, its premise, treatment options, and its overall strengths and weaknesses.

Headache and female hormones: what you need to know

The normal female lifecycle is associated with hormonal milestones, including menarche, pregnancy, contraceptive use, menopause, and the use of replacement sex hormones. Attacks of migraine without aura, but not with aura, are more likely to occur 2 days before onset and on the first 2 days of menses, but they are not more severe than those that occur outside the perimenstrual period. Oral sumatriptan and naratriptan are effective as short-term perimenstrual prophylaxis. Postdural headache can occur during the postpartum period. The International Headache Society Task Force assessed the efficacy of treatment of women who had migraine with combined oral contraceptives and hormone replacement therapy, as well as the risk of ischemic stroke associated with their use. There is no contraindication to the use of oral contraceptives in women with migraine in the absence of migraine aura or other risk factors. There is a potentially increased risk of ischemic stroke in women with migraine who are using combined oral contraceptives and have additional risk factors that cannot easily be controlled, including migraine with aura. There is no compelling evidence that postmenopausal hormone replacement therapy either decreases or increases stroke risk.