Perimenopausal Women Proven More Vulnerable to Increased Headache

BY MAURY M. BREECHER
Contributing Writer

ORLANDO - (ECCC) As women enter their perimenopausal years, they are vulnerable to an exacerbation of headache because of changes to the normal levels of estrogen and progesterone, stated Dr. Jan Lewis Brandes on July 19 at a symposium sponsored by the Diamond Headache Clinic Research and Educational Foundation.

"Fluctuation during the perimenopausal years may cause dramatic increases in both severity and frequency of migraine," said Dr. Brandes, an assistant clinical professor of neurology at Vanderbilt University in Nashville.

"Many women enter their menopausal years unaware that their previous patterns of headache represent migraine, and thus, when headache abruptly escalates, diagnosis and treatment may be delayed," she explained.

Further complicating therapy has been the use of cyclic hormonal replacement. For women whose migraine attacks are triggered by fluctuations in estrogen and progesterone, initiation of cyclic therapy "may markedly worsen her migraine," said Dr. Brandes.

"Continuous hormone replacement therapy with estrogen and, as long as the woman still has a uterus, progesterone may aid in stabilizing erratic hormonal levels and relieve migraine in the majority of patients," she added, citing her own research (JAMA 2006;19:1824-30) and that of others (Neurology 1999;53:529-3 and Cephalalgia 1984;4:227-36).

When women enter menopause and estrogen levels decline, their prevalence of migraine attacks also declines, she said. In one study, headache was reported in 76 of 556 (14%) naturally menopausal women. However, before menopause, 82% of the same women reported headache. Sixty-two percent of the women who experienced migraine or tension-type headache before menopause reported lessening of those symptoms after menopause, Dr. Brandes said.

Women at particular risk for migraine exacerbation during their perimenopausal years include those with a history of undiagnosed menstrual migraine. Indeed, after menopause, approximately two-thirds of women report a significant improvement in their migraines, according to a study published in Maturitas (Maturitas 1993;17:31-7).

Dr. Brandes said that individualized therapeutic options should be offered women with menopausal migraine. If breakthrough migraine doesn't interfere with daily activities and responds easily and quickly to moderate analgesics, cyclic hormone replacement therapy may be considered. However, if menstrual migraine is debilitating and unresponsive to abortive therapy, continuous hormone replace therapy with combined estrogen and progesterone (or estrogen alone) may offer some benefit.

"By tailoring HRT to an individual migraineur's needs, chances for migraine escalation during menopause may be minimized and patients may be ushered through a successful hormone transition," concluded Dr. Brandes.

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