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van der Arend BWH, van Casteren DS, Verhagen IE, MaassenVanDenBrink A, Terwindt GM. Continuous combined oral contraceptive use versus vitamin E in the treatment of menstrual migraine: rationale and protocol of a randomized controlled trial (WHAT!). Trials 2024; 25:123. [PMID: 38360739 PMCID: PMC10870678 DOI: 10.1186/s13063-024-07955-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/29/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Currently, there is no evidence-based hormonal treatment for migraine in women. Several small studies suggest a beneficial effect of combined oral contraceptives, but no large randomized controlled trial has been performed. As proof of efficacy is lacking and usage may be accompanied by potentially severe side effects, there is a great need for clarity on this topic. METHODS Women with menstrual migraine (n = 180) are randomly assigned (1:1) to ethinylestradiol/levonorgestrel 30/150 μg or vitamin E 400 IU. Participants start with a baseline period of 4 weeks, which is followed by a 12-week treatment period. During the study period, a E-headache diary will be used, which is time-locked and includes an automated algorithm differentiating headache and migraine days. RESULTS The primary outcome will be change in monthly migraine days (MMD) from baseline (weeks - 4 to 0) to the last 4 weeks of treatment (weeks 9 to 12). Secondary outcomes will be change in monthly headache days (MHD) and 50% responder rates of MMD and MHD. CONCLUSIONS The WHAT! trial aims to investigate effectivity and safety of continuous combined oral contraceptive treatment for menstrual migraine. Immediate implementation of results in clinical practice is possible. TRIAL REGISTRATION Clinical trials.gov NCT04007874 . Registered 28 June 2019.
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Affiliation(s)
- Britt W H van der Arend
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands.
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Verhagen IE, van der Arend BW, van Casteren DS, Thiermann NJ, Tange E, MaassenVanDenBrink A, Terwindt GM. Migraine with and without aura in relation to the menstrual cycle and other hormonal milestones: A prospective cohort study. Cephalalgia 2023; 43:3331024231164322. [PMID: 37259230 DOI: 10.1177/03331024231164322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Previous studies showed that the perimenstrual window is associated with an increased susceptibility to migraine attacks without aura, but had conflicting results regarding attacks with aura. METHODS We performed a longitudinal E-diary study among 526 premenopausal women with migraine. Differences in occurrence of perimenstrual migraine attacks between women with migraine with aura and without aura were assessed using a mixed effects logistic regression model. Additionally, participants completed a questionnaire about the influence of hormonal milestones on migraine frequency. RESULTS Prevalence of menstrual migraine did not differ between women with migraine without aura and migraine with aura (59% versus 53%, p = 0.176). The increased risk of migraine attacks without aura during the perimenstrual window was similar for women with migraine without aura (OR[95%CI]:1.53 [1.44-1.62]) and those with migraine with aura (1.53 [1.44-1.62]). The perimenstrual window was not associated with increased risk of migraine aura attacks (1.08 [0.93-1.26], p = 0.314). Women with migraine with aura more often reported increased migraine frequency during pregnancy and breastfeeding compared to women with migraine without aura, but not during hormonal contraception use. CONCLUSION Sex hormone levels seem to differently affect the trigeminovascular system (migraine headache) and the susceptibility to cortical spreading depolarization (aura). Exclusively migraine attacks without aura should be interpreted as perimenstrual attacks.
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Affiliation(s)
- Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Britt Wh van der Arend
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Niels Js Thiermann
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Evelien Tange
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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van der Arend BWH, Verhagen IE, van Leeuwen M, van der Arend MQTP, van Casteren DS, Terwindt GM. Defining migraine days, based on longitudinal E-diary data. Cephalalgia 2023; 43:3331024231166625. [PMID: 37021643 DOI: 10.1177/03331024231166625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND There is a need for standardization of the definition of a migraine day for clinical and research purposes. METHODS We prospectively compared different definitions of a migraine day with E-diary data of n = 1494 patients with migraine. We used a baseline definition based on migraine characteristics with a duration of ≥4 hours OR triptan intake (independently from its effect) OR (visual) aura lasting 5-60 minutes. RESULTS Of all migraine days defined by triptan intake only, 66.2% had a duration <4 hours. Adjusting the headache duration criterion to ≥30 minutes led to a decrease in days defined by triptan intake only and resulted in a 5.4% increase in total migraine days (equals 0.45 migraine day increase in monthly migraine days). These additional migraine days had a median duration of 2.5 hours. CONCLUSION We propose to define a migraine day as follows: 1) (a) headache duration ≥30 minutes; (b) matching ≥2 of four characteristics: unilateral, pulsating, moderate to severe pain, aggravation by or causing avoidance of routine physical activity; and (c) during headache ≥1 of the following: nausea and/or vomiting, photophobia and phonophobia or 2) (visual) aura duration 5-60 minutes or 3) a day with headache for which acute migraine-specific medication is used irrespective of its effect.
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Affiliation(s)
| | - Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthijs van Leeuwen
- Leiden Institute of Advanced Computer Science, Leiden University, Leiden, The Netherlands
| | | | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Verhagen IE, van der Arend BWH, van Casteren DS, le Cessie S, MaassenVanDenBrink A, Terwindt GM. Sex differences in migraine attack characteristics: A longitudinal E-diary study. Headache 2023; 63:333-341. [PMID: 36942410 DOI: 10.1111/head.14488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE In this prospective cohort study, characteristics of perimenstrual and non-perimenstrual migraine attacks in women were compared with migraine attacks in men. BACKGROUND Women report longer migraine attacks and more accompanying symptoms than men in cross-sectional questionnaire studies, but this has not been confirmed in longitudinal studies. Supposed differences could result from different characteristics specific to perimenstrual migraine attacks, or of attacks in women in general. METHODS This cohort study was performed among patients with migraine who were treated at the Leiden Headache Clinic. We assessed differences in migraine attack characteristics between men and women who were prospectively followed by a previously validated electronic headache diary. The primary outcome was "attack" duration. Differences between perimenstrual (Days -2 to +3 of the menstrual cycle) and non-perimenstrual attacks in women versus attacks in men were corrected for age, chronic migraine, and medication overuse headache. RESULTS A total of 1347 women and 284 men were included, reflecting the preponderance of women in migraine prevalence. Crude median (first and third quartile [Q1-Q3]) attack duration in men was 32.1 [17.7-53.6] h, compared to 36.7 [21.9-62.4] h for non-perimenstrual migraine attacks and 44.4 [17.9-79.0] h for perimenstrual migraine attacks in women. After correction for confounding, perimenstrual migraine attacks were 1.62 (95% confidence interval [CI] 1.47-1.79; p < 0.001) and non-perimenstrual 1.15 (95% CI 1.05-1.25; p = 0.003) times longer compared to migraine attacks in men. The mean relapse percentage in men was 9.2%, compared to 12.6% for non-perimenstrual migraine attacks, and 15.7% for perimenstrual migraine attacks. Relapse risk was greater for perimenstrual (odds ratio [OR] 2.39, 95% CI 1.93-2.95; p < 0.001), but not for non-perimenstrual (OR 1.18, 95% CI 0.97-1.45; p = 0.060) attacks. Migraine attacks in women were more often accompanied by photophobia, phonophobia, and nausea, but less often aura. CONCLUSION Compared to attacks in men, both perimenstrual and non-perimenstrual migraine attacks are of longer duration and are more often accompanied by associated symptoms. A sex-specific approach to migraine treatment and research is needed.
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Affiliation(s)
- Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Britt W H van der Arend
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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Verhagen IE, Spaink HA, van der Arend BW, van Casteren DS, MaassenVanDenBrink A, Terwindt GM. Validation of diagnostic ICHD-3 criteria for menstrual migraine. Cephalalgia 2022; 42:1184-1193. [PMID: 35514214 PMCID: PMC9535967 DOI: 10.1177/03331024221099031] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To assess validity of ICHD-3 diagnostic criteria for menstrual migraine. Methods We performed a longitudinal E-diary study in premenopausal women with migraine. Menstrual migraine diagnosis was self-reported at baseline, and verified according to diary based ICHD-3 criteria and a previous proposed statistical model. Validity of self-reported menstrual migraine was compared to diary based diagnosis and statistical diagnosis. Test-retest reliability and concordance between both methods were determined. Clinical characteristics of perimenstrual and non-perimenstrual migraine attacks were compared in women with and without menstrual migraine. Results We included 607 women. Both women who did and women who did not self-report to suffer from menstrual migraine fulfilled ICHD-3 criteria in the E-diary in two thirds of cases. Pure menstrual migraine was extremely rare (<1%). Concordance between statistical and diary based diagnosis was minimal (κ = 0.28, 95% CI:0.23–0.33). Women diagnosed with menstrual migraine showed 37–50% longer attack duration and increased triptan intake (OR 1.19–1.22, p < 0.001) during perimenstrual attacks. Conclusion Self-reported menstrual migraine diagnosis has extremely poor accuracy. Two thirds of women suffer from menstrual migraine, independent of self-reports. Pure menstrual migraine is rare. Women with menstrual migraine have longer attack duration and increased triptan intake during perimenstrual attacks, in contrast to women without menstrual migraine. Prospective headache (E-)diaries are required for a menstrual migraine diagnosis, also in clinical practice.
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Affiliation(s)
- Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hermes Aj Spaink
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Britt Wh van der Arend
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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van Casteren DS, Verhagen IE, van der Arend BWH, van Zwet EW, MaassenVanDenBrink A, Terwindt GM. Comparing Perimenstrual and Nonperimenstrual Migraine Attacks Using an e-Diary. Neurology 2021; 97:e1661-e1671. [PMID: 34493613 PMCID: PMC8605615 DOI: 10.1212/wnl.0000000000012723] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 08/05/2021] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Daphne S van Casteren
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Iris E Verhagen
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Britt W H van der Arend
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Erik W van Zwet
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Antoinette MaassenVanDenBrink
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gisela M Terwindt
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
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van Casteren DS, Verhagen IE, de Boer I, de Vries Lentsch S, Fronczek R, van Zwet EW, MaassenVanDenBrink A, Terwindt GM. E-diary use in clinical headache practice: A prospective observational study. Cephalalgia 2021; 41:1161-1171. [PMID: 33938248 PMCID: PMC8504420 DOI: 10.1177/03331024211010306] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Aim To determine whether our E-diary can be used to diagnose migraine and provide more reliable migraine-related frequency numbers compared to patients’ self-reported estimates. Methods We introduced a self-developed E-diary including automated algorithms differentiating headache and migraine days, indicating whether a patient has migraine. Reliability of the E-diary diagnosis in combination with two previously validated E-questionnaires was compared to a physician’s diagnosis as gold standard in headache patients referred to the Leiden Headache Clinic (n = 596). In a subset of patients with migraine (n = 484), self-estimated migraine-related frequencies were compared to diary-based results. Results The first migraine screening approach including an E-headache questionnaire, and the E-diary revealed a sensitivity of 98% and specificity of 17%. In the second approach, an E-migraine questionnaire was added, resulting in a sensitivity of 79% and specificity of 69%. Mean self-estimated monthly migraine days, non-migrainous headache days and days with acute medication use were different from E-diary-based results (absolute mean difference ± standard deviation respectively 4.7 ± 5.0, 6.2 ± 6.6 and 4.3 ± 4.8). Conclusion The E-diary including algorithms differentiating headache and migraine days showed usefulness in diagnosing migraine. The use emphasised the need for E-diaries to obtain reliable information, as patients do not reliably recall numbers of migraine days and acute medication intake. Adding E-diaries will be helpful in future headache telemedicine.
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Affiliation(s)
- Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Simone de Vries Lentsch
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Background The objective of this study was to assess whether migraine-related outcomes changed during intelligent lockdown when compared with the prior period. Methods This was a cohort study evaluating the first month of intelligent lockdown in the Netherlands (12 March to 8 April 2020) compared with one baseline month (13 February to 11 March 2020). We identified 870 migraine patients treated at the Leiden Headache Center with headache e-diaries during the period of interest. Adherence to the e-diary had to be ≥80%, yielding 592 enrolled patients. Results Intelligent lockdown led to a decrease in monthly migraine days (−0.48; 95% CI: −0.78 to −0.18, p = 0.002) and acute medication days (−0.48; 95% CI: −0.76 to −0.20, p < 0.001), and an increase in general well-being (0.11; 95% CI: 0.06 to 0.17, p < 0.001). No differences in non-migrainous headache days and pain coping were observed. Consistent results were found in a subset that was followed for 4 months. Conclusions Our findings imply that intelligent lockdown measures can improve migraine disability despite of the potential negative effects of COVID-19 and lockdown. We hypothesise that this effect is a combined result of working from home, scaling down demanding social lives, and freedom to choose how to organise one’s time.
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Affiliation(s)
| | | | | | - Gisela M Terwindt
- Gisela M Terwindt, Leiden University Medical Center, Department of Neurology, P.O. 9600, 2300 RC Leiden, the Netherlands.
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van Casteren DS, Kurth T, Danser AHJ, Terwindt GM, MaassenVanDenBrink A. Sex Differences in Response to Triptans: A Systematic Review and Meta-analysis. Neurology 2020; 96:162-170. [PMID: 33208542 DOI: 10.1212/wnl.0000000000011216] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/25/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the effect of sex on clinical response to triptans in migraine and to determine whether these differences are related to pharmacokinetics of triptans in men and women, we performed a systematic review and meta-analysis. METHODS We searched clinical trials distinguishing clinical response to or pharmacokinetic parameters of triptans between sexes in PubMed, MEDLINE, Cochrane Library, Embase, and Web of Science up to Dec 12, 2019. Analysis was based on data extracted from published reports. Male-to-female pooled risk ratios (RR) were calculated for clinical outcomes and pooled ratio of means (RoM) for pharmacokinetic outcomes using random-effects models. RESULTS Of 1,188 publications on clinical trials with triptans, 244 were identified with sex-related search terms. Only 19 publications presented sex-specific results, comprising n = 2,280 men and n = 13,899 women. No sex differences were revealed for 2-hour headache and pain-free responses, but men had a lower risk for headache recurrence (male-to-female RR 0.64, 95% confidence interval [CI]: 0.55-0.76, Q = 0.81) and adverse events (RR 0.82, 95% CI: 0.72-0.93, Q = 4.93). Men had lower drug exposure with lower area under the curve (RoM 0.69, 95% CI: 0.60-0.81, Q = 18.06) and peak drug concentration (RoM 0.72, 95% CI: 0.64-0.82, Q = 8.24) than women. CONCLUSIONS Remarkably few publications about sex differences in triptan response are available. The limited number of eligible studies show sex differences in adverse event frequency, which may be partly because of drug exposure differences. This higher drug exposure in women is not reflected in different response rates. Despite higher exposure, women have higher headache recurrence rates possibly because of longer attack duration related to sex hormonal changes.
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Affiliation(s)
- Daphne S van Casteren
- From the Department of Internal Medicine (D.S.v.C.), Erasmus University Medical Center, Rotterdam and Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Institute of Public Health (T.K.), Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Internal Medicine (A.H.J.D., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Neurology (G.M.T.), Leiden University Medical Center, Leiden, The Netherlands.
| | - Tobias Kurth
- From the Department of Internal Medicine (D.S.v.C.), Erasmus University Medical Center, Rotterdam and Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Institute of Public Health (T.K.), Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Internal Medicine (A.H.J.D., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Neurology (G.M.T.), Leiden University Medical Center, Leiden, The Netherlands
| | - A H Jan Danser
- From the Department of Internal Medicine (D.S.v.C.), Erasmus University Medical Center, Rotterdam and Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Institute of Public Health (T.K.), Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Internal Medicine (A.H.J.D., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Neurology (G.M.T.), Leiden University Medical Center, Leiden, The Netherlands
| | - Gisela M Terwindt
- From the Department of Internal Medicine (D.S.v.C.), Erasmus University Medical Center, Rotterdam and Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Institute of Public Health (T.K.), Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Internal Medicine (A.H.J.D., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Neurology (G.M.T.), Leiden University Medical Center, Leiden, The Netherlands
| | - Antoinette MaassenVanDenBrink
- From the Department of Internal Medicine (D.S.v.C.), Erasmus University Medical Center, Rotterdam and Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Institute of Public Health (T.K.), Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Internal Medicine (A.H.J.D., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Neurology (G.M.T.), Leiden University Medical Center, Leiden, The Netherlands
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van Casteren DS, Verhagen IE, Onderwater GL, MaassenVanDenBrink A, Terwindt GM. Sex differences in prevalence of migraine trigger factors: A cross-sectional study. Cephalalgia 2020; 41:643-648. [PMID: 33203218 PMCID: PMC8111230 DOI: 10.1177/0333102420974362] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIM To examine the effect of sex on migraine trigger factors. METHODS Prevalence of 11 frequently reported trigger factors was determined in a cross-sectional study among migraine patients from a validated migraine database (n = 5725 females and n = 1061 males). Female-to-male odds ratios were calculated for each trigger, using a logistic regression model with attack frequency and migraine subtype (with or without aura) as covariates. Additionally, the effect of sex on total number of triggers per individual was determined. RESULTS The top three most reported triggers in women were menstruation (78%), stress (77%), and bright light (69%). Men reported stress (69%), bright light (63%), and sleep deprivation (60%) most frequently as provoking factors. The following triggers were more often reported by women than men: Bright light (odds ratio 1.29 [95% CI 1.12-1.48]; p = 0.003), stress (1.47 [1.27-1.69]; p < 0.001), skipping a meal (1.24 [1.09-1.42]; p = 0.015), sleep deprivation (1.37 [1.20-1.57]; p < 0.001), high altitudes (1.70 [1.40-2.09]; p < 0.001), and weather changes (1.35 [1.18-1.55]; p < 0.001). Women reported more triggers than men, even when menstruation was disregarded (mean ± SD: 4.6 ± 2.3 and 4.3 ± 2.3; p < 0.001).Conclusion: Women report migraine trigger factors to be provocative of their attacks more frequently than men, which may be related to a lower migraine threshold due to sex hormonal changes.
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Affiliation(s)
- Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Division of Vascular Medicine and Pharmacology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Division of Vascular Medicine and Pharmacology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gerrit Lj Onderwater
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Linstra KM, Ibrahimi K, van Casteren DS, Wermer MJ, Terwindt GM, MaassenVanDenBrink A. Pain perception in women with menstrually-related migraine. Cephalalgia 2020; 41:417-421. [PMID: 33086876 PMCID: PMC7961656 DOI: 10.1177/0333102420966977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Cyclic hormonal fluctuations influence migraine incidence and severity. Previously, we described reduced menstrual cyclicity in estradiol levels and dermal blood flow reaction to capsaicin in female migraineurs. It is unclear whether pain perception in women with migraine is influenced by the menstrual cycle. Methods Women with menstrually-related migraine (n = 14), healthy age-matched controls (n = 10) and postmenopausal women (n = 15) were asked to grade trigeminal and non-trigeminal painful stimuli on a numeric pain rating scale on menstrual cycle day 19–21 (mid-luteal) and day 1–2 (early follicular). Results In women with menstrually-related migraine, trigeminal pain remained low throughout the cycle. Controls showed increased trigeminal pain during the mid-luteal phase compared to the early follicular phase. Changes throughout the cycle were significantly different between women with MRM and controls. Conclusion The compromised menstrual cyclicity of pain perception in women with menstrually-related migraine parallels our earlier findings on estradiol levels and dermal blood flow.
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Affiliation(s)
- Katie M Linstra
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Khatera Ibrahimi
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Daphne S van Casteren
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
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van Casteren DS, van Willigenburg FAC, MaassenVanDenBrink A, Terwindt GM. Jealousy in women with migraine: a cross-sectional case-control study. J Headache Pain 2020; 21:51. [PMID: 32393167 PMCID: PMC7216716 DOI: 10.1186/s10194-020-01114-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Estrogen influences susceptibility to migraine attacks and it has been suggested to affect jealousy in romantic relationships in women. Therefore, we hypothesized that migraine women may be more jealous. METHODS Jealousy levels and hormonal status were determined based on a cross-sectional, web-based, questionnaire study among female migraine patients and controls. A random sample of participants was selected from a validated migraine database. Participants with a serious and intimate monogamous relationship were included (n = 498) and divided into the following subgroups: menstrual migraine (n = 167), non-menstrual migraine (n = 103), postmenopausal migraine (n = 117), and premenopausal (n = 57) and postmenopausal (n = 54) controls. The primary outcome was the difference in mean jealousy levels between patients with menstrual migraine, non-menstrual migraine and premenopausal controls. Results were analyzed with a generalized linear model adjusting for age, relationship duration and hormonal status (including oral contraceptive use). Additionally, the difference in jealousy levels between postmenopausal migraine patients and controls was assessed. Previous research was replicated by evaluating the effect of combined oral contraceptives on jealousy. RESULTS Jealousy levels were higher in menstrual migraine patients compared to controls (mean difference ± SE: 3.87 ± 1.09, p = 0.001), and non-menstrual migraine patients compared to controls (4.98 ± 1.18, p < 0.001). No difference in jealousy was found between postmenopausal migraine patients and controls (- 0.32 ± 1.24, p = 0.798). Women using combined oral contraceptives were more jealous compared to non-users with a regular menstrual cycle (2.32 ± 1.03, p = 0.025). CONCLUSION Young women with migraine are more jealous within a romantic partnership.
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Affiliation(s)
- Daphne S van Casteren
- Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | | | - Antoinette MaassenVanDenBrink
- Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Abstract
Migraine prevalence is three times higher in women than in men during fertile years, which is mainly due to sex hormone differences. The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. This chapter describes the current knowledge on acute and prophylactic treatment options of migraine and other primary headache disorders during pregnancy and lactation. Further, clinical profiles of secondary headaches during pregnancy and the postpartum period are summarized.
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Affiliation(s)
- Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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