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Callum Duncan Consultant Neurologist Aberdeen Royal Infirmary

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Presentation on theme: "Callum Duncan Consultant Neurologist Aberdeen Royal Infirmary"— Presentation transcript:

1 Callum Duncan Consultant Neurologist Aberdeen Royal Infirmary
Migraine and Hormones Migraine Trust Public Meeting: September 2011 Callum Duncan Consultant Neurologist Aberdeen Royal Infirmary

2 Hormones and migraine Pre-puberty boys = girls
1st year of menstrual period 15% of women develop their 1st migraine Fertile years women:men 3:1 50% women with migraine report an association between migraine and menstruation Menopause (Migraine without aura) Commonly worsens during menopause may improve after menopause

3 Migraine frequency and menstrual cycle

4 Definitions Pure Menstrual Migraine Menstrually-related Migraine
Migraine without aura Only during menstrual period Can start anytime from 2 days before bleeding starts to 3 days after Menstrually-related Migraine As Pure Menstrual Migraine but additional attacks with or without aura at other times of the cycle


6 Menstrual vs non-menstrual attacks
Menstrual attacks are: More severe Last longer Acute treatment is not as effective Greater relapse Greater disability

7 Menstrual Migraine Women with menstrual migraine have
increased sensitivity to NORMAL hormonal changes during their menstrual cycle

8 How to treat menstrual migraine:
Modifiable lifestyle triggers Acute treatment Set limits to avoid MOH MOH less likely if short spells of frequent headache around menstruation and infrequent or no headache at other times of the month Regular preventative treatment Preventative treatment taken around period time

9 Specific Anti inflammatories
Mefenamic acid 500 mg 3 times per day Naproxen 500mg 2 times per day Work on prostaglandins produced by the womb Can be used whether periods are regular or irregular Useful if periods are heavy or painful If regular cycle: Start treatment a few days before expected first day of period and continue until period stops If irregular cycle: Start treatment on first day of period

10 The oestrogen drop in the few days before bleeding triggers migraine

11 Oestrogen to prevent menstrual migraine
Only useful when periods are regular and predictable Counter acts fall in oestrogen levels that happen a few days before period starts

12 Which oestrogens? Gel applied to the skin (arm or hip)
Oestradiol gel 1.5 mg applied daily from 2–3 days before expected first day of period for 7 days Patch Oestrogen 100 μg patch can be used from 2–3 days before expected menstruation up to day 4 or 5 two twice-weekly patches or one 7-day patch

13 Women using the combined oral contaceptive pill: Migraine during the pill free week
Typically migraine without aura Oestrogen ‘withdrawal’ Prevention Long cycle “Tricycle” 3 packs continuously followed by a pill free week Oestrogen to cover pill free week 100mcg oestradiol patches on last day of contraceptive hormones, replace after 3½ days and remove on 1st day of next pack

14 Long acting triptans to prevent menstrual migraine
Menstrual migraine is more severe, prolonged and more likely to recur Rapid onset short duration triptans Almotriptan 12.5mg Eletriptan 40mg or 80mg Rizatriptan 10mg Sumatriptan 100mg Zolmatriptan 5mg Slow onset long duration triptans Frovatriptan 2.5mg Naratriptan 2.5mg Frovatriptan has longest duration of action and can be taken once per day Naratiptan has to be taken twice per day

15 Long acting triptans to prevent menstrual migraine
Rational: menstrual migraine is more severe, prolonged and more likely to recur Only useful when periods are regular and predictable Frovatriptan 2.5mg daily 2 days before expected migraine for 6 days Naratriptan 1mg (½ 2.5mg tablet) morning and night 2 days before expected migraine for 5 days If rebound headache after triptan is stopped can take tablets for up to 8 days

16 Summary Heavy and painful periods Mefenamic acid or Naproxen
Periods unpredictable Periods predictable Frovatriptan or Naratriptan Oestrogen On Combined Oral Contraceptive Pill: Headache during pill free week 3 packs in a row

17 Combined Oral Contraceptive Pill and Migraine
Often has no effect on migraine frequency Can make migraine worse More likely to occur with migraine with aura Rarely makes migraine better Progesterone only contraceptives should have no effect on migraine pill, implant, injection, coil

18 Migraine aura and stroke
Small increased risk of stroke in people who have migraine aura Increased risk in Women Age less than 45 Smokers Use of contraceptive oestrogens No increased risk with contraceptive progestrogens } Where usual stroke risk are factors less common

19 Contraception in Migraine: (1) Combined Oral Contraceptive
Migraine with aura Contra-indicated in migraine with aura If no aura for >5years it is ok to use the combined pill, BUT must stop immediately if aura returns Migraine without aura Safe to use at any age If first migraine aura happens after starting the combined pill, it must be stopped again

20 Contraception in Migraine: (2) Progesterone
Safe to use Pill Implant Injection Coil Not associated with an increased risk of stroke

21 Migraine and Pregnancy

22 Effect of Pregnancy on Migraine
Migraine without aura Migraine gets better or stops during pregnancy in most women Migraine is more likely to stop if it is triggered by menstruation Migraine with aura More likely for attacks to continue during pregnancy Migraine aura can start for the 1st time during pregnancy 1st ever attack of migraine In person who already has migraine without aura

23 Acute treatment in Pregnancy
Pain killers Paracetamol Aspirin/NSAIDs avoid from 30 weeks (3rd trimester) avoid aspirin during breastfeeding Codeine Anti-sickness tablets Domperidone Prochlorperazine

24 Can triptans be used in pregnancy?
Risk of birth defects in the general population = 3-5% Women with migraine 3.4% (95%CI ) Sumatriptan Pregnancy Registry 1st January1996 – 31 October 2010 594 pregnancies Birth defects following exposure in 1st trimester 4.3% Birth defects following exposure in any trimester 4.3% Other triptans - insufficient data Sumatriptan/Naratriptan/Treximet Pregnancy Registry Spring 2010

25 Can triptans be used in pregnancy?
Not enough evidence to be certain Best to use as few medications as possible in pregnancy If triptans used in early pregnancy (before a woman knows she is pregnant) it is unlikely to have caused harm If attacks are very severe, especially if there is significant vomiting, it may be reasonable to use Sumatriptan

26 Triptans and breast-feeding
Risk is likely to be very small Sumatriptan Low levels of sumatriptan in breastmilk and amounts ingested by the infant are small BNF recommends withhold breast-feeding for 12 hours Others triptans BNF recommends withholding breasr-feeding for 24 hours Practically Either mix breast and bottle or have expressed milk available Express for 12 hours after Sumatriptan or 24 hours after other tripans and discard expressed milk

27 Other Acute Treatments
Paracetamol and Ibuprofen are safe Aspirin should not be used during breast-feeding Risk of Reye’s Syndrome in infant

28 Preventative treatment in Pregnancy and Breast-feeding (1)
Most migraine improves during pregnancy Preventative treatment should be avoided if possible If required use lowest dose possible and withdraw in last weeks of pregnancy Amitriptyline Has been widely used for many years No reports of limb deformities at low doses (10-50mg) Beta-blockers Risk of babies heart rate going slowly in late pregnancy (3rd trimester) and baby having low sugar levels in the first few days after birth Propranolol 10-20mg 2 times daily

29 Preventative treatment in Pregnancy and Breast-feeding (2)
Antiepileptics Should not be used in pregnancy All women of child bearing age should be counselled about risk of birth defects when prescribing an anti-epileptic for migraine prevention and must use adequate contraception Sodium Valproate contra-indicated in pregnancy Topiramate (epilepsy data): birth defects in 4.8% when on Topiramate alone birth defects in 11.2% when Topiramate given with other anti-epileptics Others migraine preventatives No evidence

30 Investigations in pregnancy
Most migraine does not require investigation Migraine symptoms that change during pregnancy or are not typical may need investigation Investigations are the same as for women who are not pregnant CT brain most radiation is to the head and the rest of the body is exposed to very limited amounts can cover the tummy with a lead blanket to protect baby MRI: safe after 1st trimester Lumbar puncture: safe

31 Migraine and the Menopause
In the menopause hormones fluctuate erratically Migraine and menstrual migraine often worsen during the menopause This persists until oestrogen levels stabilise after the menopause stops Migraine often improves after a natural menopause, but may worsen after a hysterectomy

32 Prevention for menstrual migraine during the menopause
Mefenamic acid and Naproxen can be helpful BUT Long acting triptans and oestrogen are not useful because: Ovulation must occur for oestrogen to be used and the menopause is associated with cycles where no oestrogen is produced Periods must be regular and the menopause is associated with irregular cycles

33 Hormone Replacement Therapy
HRT may worsen migraine More likely with tablets than with gel or patches Probably due to more stable hormone levels associated with gel and patch HRT HRT is safe in migraine No evidence of increased risk of stroke in patients with migraine with or without aura

34 Summary Hormones are a common migraine trigger in women
Oestrogen “withdrawal” Prostaglandins Not progesterone Migraine usually improves in pregnancy Combined Oral Contraceptives are contra-indicated in migraine with aura HRT is safe in migraine with and without aura Gel and patch are less likely to aggravate migraine

35 Questions?

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