2. The Prevalence and Diagnosis of Migraine in aPrimary Care Setting –The Landmark StudyBackground:• To determine the prevalence and diagnosis of migraine inpatients presenting to primary care physicians (PCPs) with acomplaint of headacheStudy Design:• Prospective, multi-center, international study• PCPs from 128 centers in 14 countries recruited 1203 patients• Recruited patients consulting PCP with complaint of headache• PCP diagnosed patients via customary practice• Expert panel made final headache diagnoses for patients with anew migraine diagnosis or a non-migraine diagnosis (n=377)Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting; July 16-20,2002; Lake Buena Vista, Fl.
3. Patients Presenting with HeadacheMost Likely Have MigraineOf 377 patients who returned diaries:Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting; July 16-20,2002; Lake Buena Vista, Fl.Episodic TensionHeadache3%Migrainous18%Migraine76%Other3%
4. Why Women and Migraine?• Women have Migraine 3:1 compared tomen.• In peak years (20 – 50) , Migraine affects25% of women (1 in 4).• Migraine will affect 40% of women by age50.
5. Prevalence of MigraineAge and Gender Peak prevalence at age 40 years Greatest impact on ages 25 to 55 yearsLipton RB, et al. Headache. 2001;41:646-657.0510152025300 20 30 40 50 60 70 80 90Age (years)MigrainePrevalence(%)FemalesMales
7. Migraine and Menarche• Females suffer from migraine at a 3:1 ratio tomales• Beginning with puberty, migraine is morecommon in girls• Menstrually-associated migraine begins atmenarche in 33% of women• 60-70% of female sufferers experience migraine inassociation with mensesMacGregor EA. Neurologic Clinics. 1997;15(1):125-141.Silberstein SD, Merriam GR. Neurology. 1991;41:786-793.Benedetto C et al. Cephalalgia. 1997;17(suppl 20):32-34.
8. Menstrual Migraine: Definitions• Menstrually-associated migraine (MAM):– Women who experience attacks that occur bothperimenstrually and at other times of the month– 60-70% of female migraineurs report a menstrualrelationship to their headaches– MAM is also referred to as menstrually-relatedmigraine (MRM)• Menstrual migraine (MM):– Women who experience attacks that occur onlyperimenstrually– True menstrual migraine occurs in only 7-14% offemale migraineursBenedetto C et al. Cephalalgia. 1997;17(suppl 20):32-34.
9. Role of Estrogen• Estrogen is a neuromodulator.• A decrease in estrogen increases theTrigeminal mechano- receptor field whichin turn increases pain perception andincreases cerebral vasoreactivity toserotonin.
10. Role of Estrogen• In other words, a decrease inestrogen can precipitate migraine.
11. Hormone Levels During Menstrual CycleAdapted from Hatcher RA, Trussell J, Stewart, F. Contraceptive Tecnhology, 17th Revised Ed.New York, NY. Ardent Media, Inc. 1998:Appendix, Figure 2.HORMONAL FLUCTUATIONS DURING THE MENSTRUAL CYCLE1 3 5 7 9 11 13 15 17 19 21 23 25 27 29Day of Cycle (day 0 is start of blood flow)HormoneLevelsThroughoutCycle Follicular Phase Luteal PhaseEndocrineCycleLHFSHE2POvulation
12. Treatment of Menstrual Migraine• Symptomatic• Prophylactic• Hormonal Manipulation
13. Migraine andOral Contraceptives
14. Migraine and Oral Contraception• Concerning migraine, 1/3 stay same, 1/3improve, and 1/3 worsen.• Triphasic preparations may make migraineworse due to fluctuating levels.• Lowest dose of estrogen best for migraine.• Progesterone only pills do not affectmigraine.
15. Migraine and Oral Contraception• Biggest risk of migraine is during hormonefree period.• Newer preparations like Nuvaring may bebetter due to constant low dose estrogenrelease.
16. Migraine and Oral Contraception• New or persistent Headache• New onset of migraine with aura.• Prolonged auraRed Flags
17. Migraine and Oral Contraception• Risk of stroke in healthy female <45 is 5-10 / 100,000.• Odds ratio(OR) with any migraine – 3• OR with migraine with aura – 6• OR with migraine and OC – 5 – 17 (migraine with aurahigher end)• OR with migraine, smoking, and OC - 34Risk of Stroke
18. Migraine DuringPregnancy
19. Impact of Pregnancy on Migraine• 60-70% improvement in the frequency ofmigraines, particularly in the 2nd and 3rdtrimesters• 4-8% of women experience worsening ofsymptoms• Approximately 10% of migraine cases startduring pregnancy• Pre-pregnancy headache pattern returns almostimmediately postpartum• Independent of migraine typeAube M. Neurology. 1999;53(S1):S26-S28.
20. Treatment of Migraine duringPregnancy• Treatment is challenging due to risk tobaby.• Magnesium, B2, and CoQ10 are probablysafe.• Otherwise need to weigh benefits vs risks.
21. Migraine and Lactation
22. Migraine and Lactation• Generally medications safe duringpregnancy are safe during lactation.• Notable exceptions are Benadryl andCyproheptadine.• Triptans are still recommended to pump anddump.
23. Migraine andMenopause
24. Migraine and Menopause• Preexisting Migraine– improves - 8% - 36%– worsens - 9% - 42%– unchanged - 27% - 64%• New Migraine may develop in 8% - 13%
25. Migraine and Menopause• In perimenopause, headaches may be worsedue to fluctuating hormone levels.
26. Migraine and HormoneReplacement Therapy
27. Migraine and HRT• Migraines improved - 22%• Migraines worsened - 21%• Migraines unchanged - 57%– migraines likely to be unchanged if naturalmenopause had no effect on themHodson et al /2000
28. Update on MigraineChronic Daily Headache• Typically is a bilateral, constant headachewhich occurs nearly daily• Can fluctuate in intensity and at times havecharacteristics of migraine• Are frequently “transformed migraine”
29. Update on MigraineChronic Daily Headache• Typically associated with taking analgesicmedication on a daily basis (medication overuseheadache)– acetaminophen, Excedrin, ibuprofen, butalbital,Midrin, narcotics, and even the 5HT 1b/1d agonists• Prophylactic medication will not work if analgesicrebound present