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

Prevalence, Characteristics, and Treatment Pattern of Menstrual-Related Headache Among Undergraduate Health Sciences Students at Addis Ababa University, Ethiopia

Background

Menstrual-related headache (MRH) is the most prevalent health condition among young females that limits productivity and social life. However, the magnitude of the problem and its characteristics have not been studied in Ethiopia.

Objective

This study aimed to assess the prevalence, characteristics, and treatment of MRH among undergraduate female students at the College of Health Sciences, Addis Ababa University, Ethiopia.

Methods

A cross-sectional study was conducted among undergraduate female students from May to June 2023. A random sample of 1000 females were approached who fulfilled the eligibility criteria using the online electronic method. Descriptive statistics were used to summarize participant characteristics. Multivariate logistic regression analysis was performed to identify factors associated with the severity of pain. All statistical analyses were performed using SPSS version 26. A p-value ≤ 0.05 was considered statistically significant.

Results

Of the 1000 students who approached online, 757 were included in the final analyses. The prevalence of MRH was (86, 11.4%) and 32.6% of them has experienced the headache before two to three days of menses. The median number of days of missed social activities and reduced productivity was three and one day, respectively. Being single was 6.24 times more likely to have severe MRH (AOR = 6.24, 95% CI: 2.73-14.26, p=0.001) and pharmacy students were less likely (AOR = 0.31, 95% CI: 0.16-0.61, p = 0.001) to have severe pain.

Conclusion

Our findings illustrated that MRH among young female students adversely affects students' productivity and social life. This demands interventions to reduce the impact and should pay attention in the future, particularly to create awareness to enhance screening and rendering various treatment options for the target population.

Study to Determine the Prevalence of Menstrual Migraine in Reproductive-Age Women in Saudi Arabia

BACKGROUND

Migraine is a common health condition in both men and women. Premenstrual syndrome (PMS) affects many women during their menstrual cycle, with around 50-60% of women with migraine attacks experiencing menstrual headaches. Most have mild symptoms, but 5-8% suffer from moderate to severe symptoms, causing distress and functional issues. Pure menstrual migraine (PMM) occurs in about 50% of women with migraine, and it can be debilitating in terms of frequency and severity. This information is crucial for Saudi Arabian medical professionals to provide better care and support, improving the quality of life for women with PMS and menstrual migraine (MM) attacks.

OBJECTIVES

To estimate the prevalence of MM in women, to evaluate the severity and frequency of MM in women with PMS, and to identify potential risk factors aggravating MM in women with PMS in Saudi Arabia.

METHODOLOGY

A cross-sectional community-based study was conducted on reproductive-aged (18-50 years) women who had regular menstrual cycles and were diagnosed with PMS, using a self-administered questionnaire between December 2022 to May 2023 in Saudi Arabia.

RESULTS

Out of the 2130 female participants, 397 (18.6%) had migraine. Among these 397 migraine sufferers, 230 (57.9%) experienced MM, while 167 (42.1%) had non-MM. In reproductive women in general, MM occurred in 10.7% of cases, while non-MM was observed in 7.8%. There is a correlation between increasing BMI and an increased incidence of MM. About one-third of the participants experienced moderate disability due to migraine attacks, with 134 (33.8%) individuals affected. Additionally, most MM sufferers missed at least 3 days of work in the last 3 months due to their condition.

CONCLUSIONS

Migraine attacks occurring during the menstrual cycle impair the ability to engage in social, physical, household, and academic activities, often hindering the fulfillment of professional commitments. To gain a deeper understanding of menstrual and non-menstrual migraine attacks, it is essential to conduct extensive prospective studies aimed at developing effective management strategies.

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.

Associations between Diet and Changes in Pain Levels among Young Women with Premenstrual Syndrome-A Preliminary Study during the COVID-19 Pandemic

The aim of this study was to investigate the association between PMS (premenstrual syndrome)-related pain among young women following a particular type of diet during the COVID-19 pandemic. This was compared to the period before the pandemic. Furthermore, we aimed to determine whether the increase in the intensification of pain was correlated to their age, body weight, height and BMI, and whether there are differences in PMS-related pain between women who differ in their diet. A total of 181 young female Caucasian patients who met the criteria for PMS were involved in the study. Patients were divided according to the kind of diet they had followed during the last 12 months before the first medical evaluation. The rise in pain score was evaluated according to the Visual Analog Scale before and during the pandemic. Women following a non-vegetarian ("basic") diet had a significantly higher body weight in comparison to those on a vegetarian diet. Furthermore, a significant difference was noted between the level of intensification of pain before and during the pandemic in women applying a basic diet, a vegetarian and an elimination diet. Before the pandemic, women from all groups felt weaker pain than during the pandemic. No significant difference in the intensification of pain during the pandemic was shown between women with various diets, nor was there a correlation between intensification of pain and the girl's age, BMI, their body weight and also height for any of the diets applied.

The role of purity and frequency in the classification of perimenstrual headache

BACKGROUND

Among all menstruation-associated headaches, only menstrual migraine has classification criteria in the International Classification of Headache Disorders 3rd edition (ICHD-3). Other menstruation-associated headaches are not generally described. The ICHD-3 classifies menstrual migraine according to headache type, timing(on days -2 to +3 of menstruation), frequency (whether headache occurs in at least two out of three menstrual cycles), and purity(whether headache occurs at other times of the menstrual cycle), and provides a reference for research on menstruation-associated headache. However, the role of frequency and purity in the classification of menstruation- associated headache is not clear Moreover, the potential risk factors for high-frequency and pure headaches have not been explored.

METHODS

The study was a secondary analysis of an epidemiological survey on menstrual migraine among nurses. Among nurses who had a headache on days -2 to +3 of menstruation, headache frequency, purity, and type were described. High-frequency vs. low-frequency and pure vs. impure headache were compared according to headache features, demographics, occupation-related factors, menstruation-related factors, and lifestyle factors.

RESULTS

Of all respondents, 254(18.3%) nurses who had headaches on days -2 to +3 of menstruation were included in the study. In the 254 nurses with perimenstrual headache, the proportions of migraine, tension type headache (TTH), high-frequency headache, and pure headache were 24.4%, 26.4%, 39.0%, and 42.1%, respectively. High-frequency and impure perimenstrual headache was more severe and similar to migraine. High-frequency headache was associated with more perimenstrual extremity swelling and generalized pain. Other variables were not significantly different between the groups.

CONCLUSIONS

Headache except for menstrual migraine accounts for a certain proportion of menstruation-associated headache and should not be ignored in research. Headache frequency and purity are related to headache type and should be equally considered in the classification of menstruation- associated headache. Perimenstrual extremity swelling and generalized pain are potential indicators of high-frequency perimenstrual headache.

TRIAL REGISTRATION

ChiCTR2200056429.

Clinical differences between menstrual migraine and nonmenstrual migraine: a systematic review and meta-analysis of observational studies

BACKGROUND AND PURPOSE

Approximately 60% of female migraineurs experience menstrual migraine (MM). Whether MM is a distinct clinical entity with more severe migraine attacks and a worse prognosis than nonmenstrual migraine (nMM) is still under debate. We conducted a systematic review and meta-analysis to investigate clinical differences between MM and nMM patients.

METHODS

A systematic literature search was performed to identify observational studies comparing MM and nMM patients' clinical characteristics. Quality of evidence grades of the synthesized effect estimates for each outcome were determined following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

Of 1837 identified studies, 16 were eligible for inclusion. MM patients had more migraine attacks per month (MD 0.65, 95% CI 0.05-1.24) than nMM patients; however, the quality of evidence was "low" according to the GRADE assessment. They also had more headache days (MD 0.86, 95% CI 0.12-1.60) per month, a higher rate of family history of migraine (OR 1.41 95% CI 1.12-1.78), migraine aggravation with physical activity (OR 1.60, 95% CI 1.35-1.89), a younger age at migraine onset (MD - 0.99, 95% CI - 1.78 to - 0.19), and a higher risk of accompanying symptoms (OR 2.31, 95% CI 1.72-3.10) than nMM patients; however, the quality of evidence was "very low".

CONCLUSIONS

There were differences between MM and nMM, showing that MM patients have a worse profile than nMM patients, but the quality of evidence is too low to draw definite conclusions on the separation/unification of the two clinical entities.

Clinical features of migraine with onset prior to or during start of combined hormonal contraception: a prospective cohort study

Many studies have described the features of menstrually related migraines but there is a lack of knowledge regarding the features of migraine in combined hormonal contraceptive users (CHC). Hormone-withdrawal migraines in the pill-free period could differ from those in the natural cycle. Gynaecologic comorbidities, like dysmenorrhea and endometriosis, but also depression or a family history might modify the course of migraine. A better understanding of migraine features linked to special hormonal situations could improve treatment. For this prospective cohort study, we conducted telephone interviews with women using a CHC and reporting withdrawal migraine to collect information on migraine frequency, intensity, triggers, symptoms, pain medication, gynaecologic history and comorbidities (n = 48). A subset of women agreed to also document their migraines in prospective diaries. The mean number of migraine days per cycle was 4.2 (± 2.7). Around 50% of these migraines occurred during the hormone-free interval. Migraine frequency was significantly higher in women who suffered from migraine before CHC start (5.0 ± 3.1) (n = 22) in comparison to those with migraine onset after CHC start (3.5 ± 2.1) (n = 26). Menstrually related attacks were described as more painful (57.5%), especially in women with migraine onset before CHC use (72%) (p < 0.02). Comorbidities were rare, except dysmenorrhea. The majority of migraine attacks in CHC users occur during the hormone-free interval. Similar as in the natural cycle, hormone-withdrawal migraines in CHC users are very intense and the response to acute medication is less good, especially in those women, who developed migraine before CHC use.

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.

Cerebrovascular Function in Hormonal Migraine: An Exploratory Study

Background: Migraineurs, particularly young premenopausal women, are at increased risk of cerebrovascular disease; however, there is currently limited evidence as to whether hormonal migraine is associated with poor cerebrovascular function.

Objectives: The objectives of this study were to: (1) investigate the potential association of cerebrovascular function with hormonal migraine and (2) determine whether abnormalities of cerebrovascular function in hormonal migraineurs are associated with migraine-related disability and/or quality of life.

Method: A cross-sectional study was undertaken in 50 hormonal migraineurs (mean age: 38.7 ± 1.2 years) and 29 controls (mean age: 35.6 ± 1.8 years). Data were collected at a single point in time from all participants during the inter-ictal period when they were free from migraine and not menstruating. Transcranial Doppler ultrasound was used to measure resting blood flow velocity and cerebrovascular responsiveness (CVR) to hypercapnia and cognitive stimulation (neurovascular coupling) in the left and right middle cerebral artery (MCA). Additionally, hormonal migraineurs completed three questionnaires to assess migraine-related disability and quality of life as well as migraine frequency and intensity: Headache Impact Test-6™, Migraine-Specific Quality of Life and Migraine Disability Assessment.

Results: Hormonal migraineurs had lower resting mean blood flow velocity (MBFV) (P = 0.009) and neurovascular coupling during cognitive stimulation (P = 0.010) in the left MCA than controls. No such differences were found in the right MCA. Additionally, heart rate (P = 0.004) was higher in hormonal migraineurs than controls. However, no differences in CVR to hypercapnia were found between hormonal migraineurs and controls. Multi-variate analysis revealed age to be a significant (P = 0.012) predictor of MBFV in the left MCA. Negative correlations between headache frequency and CVR to hypercapnia in the left (P = 0.026) and right MCA (P = 0.044) were found. Additionally, negative correlations between neurovascular coupling during the 2-Back 1.5 s task in the right MCA and the MSQoL emotional (P = 0.013) and role-function restrictive (P = 0.039) domains were found.

Conclusions: This is the first study to show that hormonal migraineurs have poorer cerebrovascular function, as represented by lower resting MBFV and impaired neurovascular coupling in the left MCA. Future studies should investigate whether improving cerebrovascular function can prevent hormonal migraine and improve quality of life.

Clinical Trial Registration: ACTRN12618001230246.

Mapping Assessments Instruments for Headache Disorders against the ICF Biopsychosocial Model of Health and Disability

Headache disorders have a strong impact on sufferers’ lives. However, the “content” of assessment instruments addressing concepts, such as disability and quality of life (QoL), has not comprehensively been addressed. We searched SCOPUS for research papers in which outcome measures were used in adult populations of patients with migraine, tension-type headache (TTH), and cluster headache (CH). The content of single instruments was then mapped against the International Classification of Functioning, Disability, and Health. A total of 150 papers and 26 instruments were included: 15 addressed disability or impact, two addressed work-related difficulties, and nine addressed QoL. Few instruments were commonly used across the conditions and covered domains of functioning were impact on daily life activities, homework, school, and work-related tasks, leisure time, informal and family relations, pain, emotional difficulties, energy level, and impulse control. Most of the research is based on instruments that were developed for migraine, which is critical for CH, and the impact of headache disorders on work-related activities is poorly acknowledged. Further research is needed to expand the scope of headaches impact on daily life activities, and on environmental factors relevant to headache disorders to raise knowledge on the less represented areas, e.g., TTH impact.

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.

Pain rates in general population for the period 1991-2015 and 10-years prediction: results from a multi-continent age-period-cohort analysis

Background

Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people. The aims of this study are to evaluate the temporal variations of pain rates among general populations for the period 1991–2015 and to project 10-year pain rates.

Methods

We used the harmonized dataset of ATHLOS project, which included 660,028 valid observations in the period 1990–2015 and we applied Bayesian age–period–cohort modeling to perform projections up to 2025. The harmonized Pain variable covers the content “self-reported pain experienced at the time of the interview”, with a dichotomous (yes or no) modality.

Results

Pain rates were higher among females, older subjects, in recent periods, and among observations referred to cohorts of subjects born between the 20s and the 60s. The 10-year projections indicate a noteworthy increase in pain rates in both genders and particularly among subjects aged 66 or over, for whom a 10–20% increase in pain rate is foreseen; among females only, a 10–15% increase in pain rates is foreseen for those aged 36–50.

Conclusions

Projected increase in pain rates will require specific interventions by health and welfare systems, as pain is responsible for limited quality of subjective well-being, reduced employment rates and hampered work performance. Worksite and lifestyle interventions will therefore be needed to limit the impact of projected higher pain rates.

Assessment of menstrual health status and evolution through mobile apps for fertility awareness

For most women of reproductive age, assessing menstrual health and fertility typically involves regular visits to a gynecologist or another clinician. While these evaluations provide critical information on an individual's reproductive health status, they typically rely on memory-based self-reports, and the results are rarely, if ever, assessed at the population level. In recent years, mobile apps for menstrual tracking have become very popular, allowing us to evaluate the reliability and tracking frequency of millions of self-observations, thereby providing an unparalleled view, both in detail and scale, on menstrual health and its evolution for large populations. In particular, the primary aim of this study was to describe the tracking behavior of the app users and their overall observation patterns in an effort to understand if they were consistent with previous small-scale medical studies. The secondary aim was to investigate whether their precision allowed the detection and estimation of ovulation timing, which is critical for reproductive and menstrual health. Retrospective self-observation data were acquired from two mobile apps dedicated to the application of the sympto-thermal fertility awareness method, resulting in a dataset of more than 30 million days of observations from over 2.7 million cycles for two hundred thousand users. The analysis of the data showed that up to 40% of the cycles in which users were seeking pregnancy had recordings every single day. With a modeling approach using Hidden Markov Models to describe the collected data and estimate ovulation timing, it was found that follicular phases average duration and range were larger than previously reported, with only 24% of ovulations occurring at cycle days 14 to 15, while the luteal phase duration and range were in line with previous reports, although short luteal phases (10 days or less) were more frequently observed (in up to 20% of cycles). The digital epidemiology approach presented here can help to lead to a better understanding of menstrual health and its connection to women's health overall, which has historically been severely understudied.