Recognition and treatment of menstrual migraine

Progesterone Receptor Activation Regulates Sensory Sensitivity and Migraine Susceptibility

Women develop chronic pain during their reproductive years more often than men, and estrogen and progesterone regulate this susceptibility. We tested whether brain progesterone receptor (PR) signaling regulates pain susceptibility. During the estrous cycle, animals were more sensitive to mechanical stimulus during the estrus stage than in the diestrus stage, suggesting a role for reproductive hormones, estrogen, and progesterone. Progesterone treatment of ovariectomized and estrogen-primed mice caused a delayed reduction in the mechanical threshold. Segesterone, a specific agonist of PRs replicated this effect, whereas, the segesterone-induced reduction in mechanical threshold was blocked in the mice lacking PRs in the nervous system. Segesterone treatment also did not alter mechanical threshold in adult male and juvenile female mice. PR activation increased the cold sensitivity but did not affect the heat and light sensitivity. We evaluated whether PR activation altered experimental migraine. Segesterone and nitroglycerin when administered sequentially, reduced the pain threshold but not when given separately. PRs were expressed in several components of the migraine ascending pain pathway, and their deletion blocked the painful effects of nitroglycerin. PR activation also increased the number of active neurons in the components of the migraine ascending pain pathway. These studies have uncovered a pain-regulating function of PRs. Targeting PRs may provide a novel therapeutic avenue to treat chronic pain and migraine in women. PERSPECTIVE: This article provides evidence for the role of progesterone receptors in regulating pain sensitivity and migraine susceptibility in females. Progesterone receptors may be a therapeutic target to treat chronic pain conditions more prevalent in women than men.

Progesterone receptor activation regulates sensory sensitivity

Women develop chronic pain during their reproductive years more often than men, and estrogen and progesterone regulate this susceptibility. We tested whether brain progesterone receptor (PR) signaling regulates pain susceptibility. During the estrous cycle, animals were more sensitive to pain during the estrus stage than in the diestrus stage, suggesting a role for reproductive hormones, estrogen, and progesterone. We measured the pain threshold daily for four days in ovariectomized, estrogen-primed animals treated with progesterone. The pain threshold was lower 2 days later and stayed that way for the duration of the testing. A specific progesterone-receptor (PR) agonist, segesterone, promoted pain, and mice lacking PR in the brain (PRKO) did not experience lowered pain threshold when treated with progesterone or segesterone. PR activation increased the cold sensitivity but did not affect the heat sensitivity and had a small effect on light sensitivity. Finally, we evaluated whether PR activation altered experimental migraine. Segesterone and nitroglycerin (NTG) when administered sequentially, reduced pain threshold but not separately. These studies have uncovered a pain-regulating function of PRs. Targeting PRs may provide a novel therapeutic avenue to treat chronic pain in women.

A meta-analysis investigating the prevalence and moderators of migraines among people with bipolar disorder

BACKGROUND

Uncertainty exists regarding the prevalence and moderators of migraine comorbidity among people with bipolar disorder (BD). We conducted a meta-analysis and meta-regression to investigate the prevalence and moderators of migraine among people with BD.

METHOD

Two authors independently searched major electronic databases from inception till 02/2015. Articles were included that reported the prevalence of migraine in people with BD with or without a control group. A random effects meta-analysis and exploratory meta-regression were conducted.

RESULTS

Fourteen studies were included encompassing 3976 individuals with BD (mean age 35.5 years, SD 7.6, 29% male). The overall pooled prevalence of migraine was 34.8% (95% CI=25.54-44.69). The prevalence of migraine was higher among people with BD-II (54.17%, 95% CI=31.52-75.95, n=742) compared to BD-I (32.7%, 95% CI=18.16-49.19, n=2138, z=3.97, p<0.0001). The prevalence of migraine was 33.9% (95% CI=26.02-42.44), 39.5% (95% CI=18.81-62.39) and 47.11% (95% CI=22.24-72.77) in North America, Europe and South America respectively. The prevalence of migraine was higher when classified according to recognized criteria at 47.91% (95% CI=32.51-63.5) compared to non-recognized criteria (20.0%, 95% CI=12.44-29.06, z=-8.40, p<0.0001). Meta regression suggests mean age may be a potential moderator.

CONCLUSION

Migraine is common and burdensome among people with BD. People with BD-II appear to be particularly affected. Nonetheless, future research is required to better understand these relationships, with a special emphasis toward the course specifiers of comorbid migraine cases of either BD-I vs. BD-II.

Prevalence and clinical features associated to bipolar disorder-migraine comorbidity: a systematic review

BACKGROUND

The prevalence and clinical features associated with bipolar disorders (BDs)-migraine comorbidity have been reported inconsistently across different studies, therefore warranting a systematic review on the matter.

METHODS

A systematic review was conducted in accordance with the PRISMA statement searching major electronic databases for documents indexed between January, 2000 and July, 2014. Eligible studies were those including quantitative data on prevalence rates and clinical features associated to BD-migraine comorbidity; case reports excluded. Three authors independently conducted searches, quality assessment of the studies and data extraction.

RESULTS

Several cross-sectional studies, and a handful of retrospective follow-up studies or non-systematic reviews assessed the prevalence and/or the clinical correlates of migraine-BD comorbidity. High prevalence rates and a significant burden of BD-migraine comorbidity were common findings, particularly in case of BD-II women (point-prevalence rates up to 77%), migraine with aura (up to 53%) and/or cyclothymic temperament (up to 45% of the cases).

LIMITATIONS

Some of the biases encountered in a few studies accounted by the present review may nonetheless have hampered the generalizability of the overall conclusions drawn herein.

CONCLUSIONS

BD-migraine comorbidity may comprise of a sub-phenotype of BDs requiring patient-tailored therapeutic interventions to achieve an optimal outcome. Specifically, additional studies including longitudinal follow-up studies are aimed in order to shed further light on the actual prevalence rates and clinical features associated to BD-migraine comorbidity, with a special emphasis towards the clinically suggestive potential connection between mixed features, bipolar depression, migraine, and increased risk for suicidality. PROSPERO registration number: CRD42014009335.

Acupuncture as prophylaxis for menstrual-related migraine: study protocol for a multicenter randomized controlled trial

BACKGROUND

Menstrual-related migraine is a common form of migraine affecting >50% of female migraineurs. Acupuncture may be a choice for menstrual-related migraine, when pharmacological prophylaxis is not suitable. However, the efficacy of acupuncture has not been confirmed. We design and perform a randomized controlled clinical trial to evaluate the efficacy of acupuncture compared with naproxen in menstrual-related migraine patients.

METHODS/DESIGN

This is a multicenter, single blind, randomized controlled clinical trial. A total of 184 participants will be randomly assigned to two different groups. Participants will receive verum acupuncture and placebo medicine in the treatment group, while participants in the control group will be treated with sham acupuncture and medicine (Naproxen Sustained Release Tablets). All treatments will be given for 3 months (menstrual cycles).The primary outcome measures are the change of migraine days inside the menstrual cycle and the proportion of responders (defined as the proportion of patients with at least a 50% reduction in the number of menstrual migraine days). The secondary outcome measures are the change of migraine days outside the menstrual cycle, duration of migraine attack, the Visual Analogue Scale (VAS), and intake of acute medication. The assessment will be made at baseline (before treatment), 3 months (menstrual cycles), and 4 months (menstrual cycles) after the first acupuncture session.

DISCUSSION

The results of this trial will be helpful to supply the efficacy of acupuncture for menstrual-related migraine prophylaxis.

TRIAL REGISTRATION ISRCTN

ISRCTN57133712.

Migraine headache and ischemic stroke risk: an updated meta-analysis

BACKGROUND

Observational studies, including recent large cohort studies that were unavailable for prior meta-analysis, have suggested an association between migraine headache and ischemic stroke. We performed an updated meta-analysis to quantitatively summarize the strength of association between migraine and ischemic stroke risk.

METHODS

We systematically searched electronic databases, including MEDLINE and EMBASE, through February 2009 for studies of human subjects in the English language. Study selection using a priori selection criteria, data extraction, and assessment of study quality were conducted independently by reviewer pairs using standardized forms.

RESULTS

Twenty-one (60%) of 35 studies met the selection criteria, for a total of 622,381 participants (13 case-control, 8 cohort studies) included in the meta-analysis. The pooled adjusted odds ratio of ischemic stroke comparing migraineurs with nonmigraineurs using a random effects model was 2.30 (95% confidence interval [CI], 1.91-2.76). The pooled adjusted effect estimates for studies that reported relative risks and hazard ratios, respectively, were 2.41 (95% CI, 1.81-3.20) and 1.52 (95% CI, 0.99-2.35). The overall pooled effect estimate was 2.04 (95% CI, 1.72-2.43). Results were robust to sensitivity analyses excluding lower quality studies.

CONCLUSIONS

Migraine is associated with increased ischemic stroke risk. These findings underscore the importance of identifying high-risk migraineurs with other modifiable stroke risk factors. Future studies of the effect of migraine treatment and modifiable risk factor reduction on stroke risk in migraineurs are warranted.

A prospective comparison between ICHD-II and probability menstrual migraine diagnostic criteria

OBJECTIVE

To prospectively evaluate the diagnosis of menstrual migraine (MM) by comparing 2 diagnostic systems.

METHODS

Female migraineurs self-reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD-II) criteria and a probability model called Probability MM.

RESULTS

Three months of pretreatment prospective diaries were completed by 126 women. ICHD-II menstrually related migraine was diagnosed in 73.8% with pure MM in 7.1%. ICHD-II and Probability diagnoses agreed for all cases of ICHD-II non-MM and pure MM, with disagreement among women diagnosed with ICHD-II menstrually related migraine, only half of whom were identified as having a relationship with menses greater than chance alone using the Probability model. Interestingly, 20% of those women self-reporting a substantial relationship between migraine and menses were not prospectively diagnosed with MM using either diagnostic system. Differences in menstrual vs nonmenstrual headaches were greater when using the Probability model.

CONCLUSIONS

Prospective headache diaries are needed to diagnose MM. A probability-based method, which considers the chance occurrence of headaches during the menstrual cycle, identifies fewer women as having menstrually related migraine compared with the diary-based methods recommended by the current ICHD-II candidate criteria.

Menstrual cycle-related exacerbation of disease

Exacerbation of common medical and mental health disorders at specific phases of the menstrual cycle is a prevalent phenomenon. Although the precise cause is unclear, studies implicate complex interactions between the immune and neuroendocrine systems. The menstrual cycle also is a trigger for the onset of depressive disorders, including premenstrual dysphoric disorder, a disorder specific to the luteal phase of the menstrual cycle, and depression associated with the transition to menopause. This article discusses common mental health problems exacerbated by the menstrual cycle, with a particular focus on premenstrual dysphoric disorder and perimenopausal depression. Throughout the reproductive lifespan, routine screening and assessment for the presence of common psychiatric disorders are critical for accurate diagnosis and provision of effective treatment. Management options include referral or consultation with a primary care provider or psychiatrist; treatment options for premenstrual dysphoric disorder and perimenopausal depression include pharmacotherapy with antidepressant agents and/or psychotherapy. Hormones may be helpful.