This document provides information about migraine in women. Some key points:
- Migraine is 3 times more common in women than men. Hormonally-associated migraines affect 12 million women in the US.
- Migraines are often associated with changes in hormone levels, such as during menstruation, pregnancy, use of oral contraceptives, and menopause.
- Diagnosis of migraine involves evaluating symptoms such as headache duration/intensity, nausea, light/sound sensitivity, visual/sensory disturbances (aura).
- Treatment involves both acute symptomatic relief and preventive medications, though choices are more limited during pregnancy/breastfeeding due to safety.
Safety Considerations in the use of Psychotropic Medication in Children and T...Stephen Grcevich, MD
This presentation for the medical staff of Child and Adolescent Behavioral Health in Canton, OH is an introduction to basic safety concerns and monitoring associated with the use of psychotropics in children and teens. The presentation was tailored to newly graduated advanced practice nurses.
[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)Alex J Mitchell
This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
Safety Considerations in the use of Psychotropic Medication in Children and T...Stephen Grcevich, MD
This presentation for the medical staff of Child and Adolescent Behavioral Health in Canton, OH is an introduction to basic safety concerns and monitoring associated with the use of psychotropics in children and teens. The presentation was tailored to newly graduated advanced practice nurses.
[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)Alex J Mitchell
This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
Diabetes mellitus and erectile dysfunction by Dr. Mohand Yaghi PgDip (urol) C...Mohand Yaghi
A lecture about the effect of diabetes mellitus on the erectile function. Dr. Mohand Yaghi was an invited speaker in Al-Jahra scientific day, Kuwait 2015.
Erectile Dysfunction: New Paradigms in Treatment Ranjith Ramasamy
1. Discuss diagnosis of erectile dysfunction
2. Treatments of ED using Viagra, Cialis, Trimix (intracavernosal injections)
3. Evaluate penile prosthesis and implant as ED surgical therapy options
Physical monitoring in Mental Illness - Dr Sadgun BhandariDr Sadgun Bhandari
Physical monitoring in Mental Illness - Dr Sadgun Bhandari is a recognized member of the Royal College of Psychiatrists, UK and also a Fellow of the Royal College of Psychiatrists, UK.
Treatment of epilepsy polytherapy vs monotherapyPramod Krishnan
This presentation reviews the evidence regarding use of early polytherapy in patients with epilepsy with regards to seizure control and adverse effects. The advantages and disadvantages of polytherapy compared to monotherapy is addressed.
LGS Foundation 2016 Conference - Saturday AfternoonLGS Foundation
Topics Include: Expecting to Transition - Reframing the Journey presented by Amy Miller, MSN, MA, PCNS-BC, ACHPN, Individual Education Program (IEPs) presented by Dena Hook, Telling Your Story presented by Patricia Moore and Dietary Therapies: Creative Strategies presented by Stephanie Criteser, RD, CSP and Natalie Cummings, RD
Diabetes mellitus and erectile dysfunction by Dr. Mohand Yaghi PgDip (urol) C...Mohand Yaghi
A lecture about the effect of diabetes mellitus on the erectile function. Dr. Mohand Yaghi was an invited speaker in Al-Jahra scientific day, Kuwait 2015.
Erectile Dysfunction: New Paradigms in Treatment Ranjith Ramasamy
1. Discuss diagnosis of erectile dysfunction
2. Treatments of ED using Viagra, Cialis, Trimix (intracavernosal injections)
3. Evaluate penile prosthesis and implant as ED surgical therapy options
Physical monitoring in Mental Illness - Dr Sadgun BhandariDr Sadgun Bhandari
Physical monitoring in Mental Illness - Dr Sadgun Bhandari is a recognized member of the Royal College of Psychiatrists, UK and also a Fellow of the Royal College of Psychiatrists, UK.
Treatment of epilepsy polytherapy vs monotherapyPramod Krishnan
This presentation reviews the evidence regarding use of early polytherapy in patients with epilepsy with regards to seizure control and adverse effects. The advantages and disadvantages of polytherapy compared to monotherapy is addressed.
LGS Foundation 2016 Conference - Saturday AfternoonLGS Foundation
Topics Include: Expecting to Transition - Reframing the Journey presented by Amy Miller, MSN, MA, PCNS-BC, ACHPN, Individual Education Program (IEPs) presented by Dena Hook, Telling Your Story presented by Patricia Moore and Dietary Therapies: Creative Strategies presented by Stephanie Criteser, RD, CSP and Natalie Cummings, RD
This PPT focuses on the diagnosis and treatment of the primary headache disorders, with special emphasis on migraine, the headache most likely to bring patients to physicians and pharmacists. warning signs of the ominous headache, which, although rare, can herald a life-threatening condition. Clinical characteristics of the primary headache types, migraine, tension-type headache, and cluster headache, are described
It is a brief presentation on headache disorders. My reference was mainly Medscape. I mentioned treatment in a concise way so you may want to read up more on that.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
3. Migraine is a Female Disorder
Average lifetime percent of population
with migraine:
22.6% women (range 13-32%)
10.5% men (range 5.7-9%)
Women are roughly 3 times as likely as
men to have migraine
Hormonally associated migraine affect 12
million women in the U.S.
4. Is it Migraine?
Migraine without Aura
At least 5 attacks
Headache lasts 4-72 hours (untreated) in adults,
1-72 hours in children
At least 2 of the following:
Unilateral location
Pulsating quality
Moderate or severe intensity
Aggravated by routine physical activity
During the headache, at least 1 of the following:
Nausea and/or vomiting
Photophobia and phonophobia
5. Migraine with Aura
At least 2 attacks Scintillating scotoma
At least 3 of the following:
Fully reversible aura symptoms explained
by focal brain dysfunction
At least one aura symptoms evolving over
at least 4 minutes or two or more
symptoms in succession
Each symptom lasts less than 60 minutes
Headache usually begins during or follows
the aura
6. Sensory
Paresthesias (tongue; hand-mouth)
Motor
Unilateral or bilateral weakness (spreads)
Olfactory
Gustatory hallucinations
Vertigo/dizziness
Common (50%) but does not distinguish
migraine with/without aura
Fortification spectra
7. Speech
Dysarthria
Aphasia
Behavioral
Depersonalization
Automatic behavior
Transient global amnesia
Emotional (anxiety, euphoria)
Déjà vu (strange things look familiar)
Jamais vu (familiar things look strange)
8. Other
Diplopia
Ptosis
Altered level of consciousness
Ataxia
Unilateral episodic mydriasis
Auditory
What’s not aura
Blurred vision
Premonitory photophobia, phonophobia,
nausea
9. Quick and Easy Migraine Diagnosis:
“I.D. Migraine”
1. Headache related
disability
2. Photophobia
3. Nausea
93% of migraineurs have 2 of 3 features
81% sensitivity, 75% specificity
Aura 100% sensitive
10. Phases of Migraine
Pre-Headache Headache Post-Headache
Premonitory Aura Postdrome
symptoms*
Mild Moderate Severe
*Yawning, mood
change, sleepiness,
food cravings,
excessive thirst or
urination
11. Taking the History: The American
Migraine Communication Study
60 visits (approximately 12 minutes each)
between healthcare professionals (primary
care, neurologists, NP) and patients were
video and audio-recorded
Post-visit interviews were conducted
separately with patients and healthcare
professionals
All interviews were transcribed and analyzed
looking for discordance
12. Findings
91% of the questions asked were closed-
ended or short-answer
90% of visits did not address impairment
in any way (60% were severely impaired
during attacks; average frequency
5/month)
Of the 50 patients, 35 were not on a
preventive medication after the first visit
Prevention was only mentioned in 50% of
the 25 patients who would qualify for
one based on standard guidelines
13. Suggestions for Improving
Communication
Patient-centered interviewing focused on
disability:
“How do migraines affect your daily life?”
“How does migraine affect your work and
family?”
“How does migraine make you feel – even
when you aren’t having one?”
14. Other General Features
Migraine changes throughout life
Migraine may change with hormones
You can have a migraine without a
headache
Children get migraines too
People with migraine often get other
kinds of headaches as well
It runs in the family
15. Occurs in the peak productive
years
Migraine affects:
18% of women
6.5% of men
7% of children
16. Estrogen Paradox
Being female increases the likelihood of
having migraine (estrogen)
Sudden decreases in estrogen can trigger
migraine headaches
Fall in estrogen
Prior to menses
Pill free week of oral contraceptives
Perimenopause
Postpartum
17. Migraine Throughout
the (Hormonal) Life Cycle
Children
Adolescence – Puberty
Menstruation
Pregnancy
Menopause
Other:
Hormone replacement therapy
Oral contraceptives
18. Migraine in Children
Boys=girls prior to puberty
Peak incidence of
migraine with aura
Boys – age 5
Girls – age 12-13
Peak incidence of migraine
without aura
Boys – age 10-11
Girls – age 14-17
After puberty ratio is 3 to 1
(girls to boys)
Boys often outgrow them
19. Migraine in Childhood
Under-diagnosed
Young children may not be
able to describe pain or
associated features
Nausea, vomiting, sensitivity
to light and noise is inferred
Headaches are often shorter than
in adults
20. Think about migraine in children with:
Episodes of unexplained vomiting and
abdominal pain lasting an hour or more
Attacks of imbalance or dizziness lasting
minutes
Recurring attacks of head tilt, vomiting,
imbalance lasting hours to days
Alternating one-sided weakness
Headaches followed by droopy eyelid and
double vision (lasting days to weeks)
21. Migraine and Menstruation
60-70% of women with migraine have
them with menstruation
Pure Menstrual Migraine
2 days prior to menses to 4th day of
menses only (14% of women) for 2 of 3
cycles
Menstrually-Related Migraine
Within the above window and at other
times of the month
Perimenstrual Migraine
Attacks 2-7 days prior to menses
Keep a diary! Compare menstrual and
non-menstrual attacks.
22.
23. May Be Associated with Other
Features of PMS
(DSM-4: 5 days before to 4 days into menses,
interfere with activities)
Affective Physical
Depression Breast tenderness
Angry outbursts Abdominal bloating
Irritability Headache
Anxiety Peripheral edema
Confusion Acne
Social withdrawal Cramping
Food cravings
Increased appetite
Sexual disinterest
24. What’s Different During Menses?
No difference in sex hormones
between migraineurs and
controls (testosterone, LH, FSH)
Headaches more severe, more
nausea and vomiting
Treatments may not
be as effective during
menses (?)
Loder E. Neurol Sci 2005;26:S121-124
25. Treatment of Menstrual Migraine
Acute symptomatic treatment
Migraine specific, anti-inflammatories
Standard preventive treatment
Short-term preventive treatment (“mini-
prevention”)
Non-steroidal anti-inflammatories
Long-acting triptans (frova) or ergots
Magnesium
Hormonal therapy (estradiol gel)
Increase usual preventative
Non-pharmacologic therapy
**Pringsheim T, et al. Acute treatment and prevention of menstrually
related migraine headache. Neurology 2008;70:1555-1563
26. Use of Oral Contraceptives to
Prevent Menstrual Migraine
1. Extended cycle OCs
Suppress ovulation for months
May have breakthrough bleeding in first few
months (accompanied by migraine)
2. Reduce monthly decline in estrogen
Use low-dose estrogen instead of 7 placebo pills
each month
3. Contraceptive patch + vaginal ring
Less daily fluctuation in estrogen level
27. Migraine and Pregnancy
Better (50-60+%)
Worse (15-%)
The Same (25%)
May worsen during the first trimester
May only occur during pregnancy
May be headache free in last trimester
28. New Onset of Headaches During
Pregnancy
Increased intracranial pressure
Tension-type headache
Cerebral venous sinus thrombosis
Stroke
Tumor
Vasculitis
Intracranial hemorrhage
Reversible cerebrovasoconstrictive
syndrome (RCVS)
29. Headache Medications and
Pregnancy – General Concepts
Pharmakokinetics vary during gestation
Increased plasma volume – increase
unbound drug
Decreasing albumin – increase free
fraction (total assays unreliable)
Increased renal clearance
Changes in CYP and glucuronidation
**Lucas S. Medication Use in the Treatment of Migraine
During Pregnancy and Lactation. Curr Pain Headache
Rep 2009;13:392-398.
30. Symptomatic Treatment of Migraine
During Pregnancy (Category B – no
evidence of risk but no studies)
Acetaminophen
Caffeine
Ibuprofen*
Indomethacin*
Naproxen*
Meperidine
Morphine
Prednisone
*Avoid in third trimester
31. Barbiturates, opioids,
benzodiazepines
Neonatal withdrawal syndrome
Opioids are category B
Beware medication overuse
Triptans are all category C
Ergots are contraindicated
34. Breast Feeding – General Principles
No evidence that
lactation worsens
migraine
Safe in pregnancy ≠ safe
in lactation
Amount passed to breast
milk depends on:
• average plasma
concentration
• amount excreted into
breast milk
• volume of milk
ingested
35. Is the drug necessary?
Use the safest one
Consider measuring blood levels in
the infant
Take medication after completing a
breast feeding to minimize
exposure to the baby
36. Symptomatic Treatment While Breast
Feeding
Concern
Compatible Benzodiazepines
Acetaminophen, Contraindicated
caffeine, NSAID Antihistamines
Caution Ergotamine/DHE
Aspirin,
barbiturates
Triptans
37. Preventive Treatment While Breast
Feeding
Concern
Compatible Tricyclic
Beta blockers antidepressants
Calcium blockers Verapamil
Valproate Contraindicated
Corticosteroids Bromocriptine
Amitriptyline
**Hale TW. Medications and
Caution Mother’s Milk. Amarillo, TX, Hale
Publishing, 2008.
SSRI
38. Perimenopause
Women with a history of menstrual
migraine (“hormonally sensitive”)
may have worsening of migraines in
peri-menopause
Treatment:
Hormone replacement therapy
Low dose OC (without placebo week)
Standard migraine therapies
39. Menopause
Migraine and natural
menopause:
20-40% worsen
20-30% improve
30-50% unchanged
Effect of surgical menopause:
(hysterectomy, oophorectomy)
38-87% worsen
Some women develop migraines
for the first time at menopause
40. Hormone Replacement Therapy?
Conflicting data regarding migraine
Considerations:
Delivery (patch*, cream, pill, injection)
Need for continuous use
Type and dosage
Natural estrogens (estradiol) are better
tolerated than conjugated estrogen
One size does not fit all
Risk-benefit ratio
41. Migraine and Stroke
Women under 45
Posterior circulation strokes and white
matter lesions more likely in MWA and
high attack frequency of migraine than
controls
Women 45 years and older
MWA twice as likely to develop ischemic
stroke and MI over 10 years of follow-up
43. Migraine and Stroke
Numerous studies document increase
risk:
National Health and Nutrition Examination
Survey – prospective (11,777 men and
women; RR 2.1)
Meta-analysis of 14 observational studies
Risk among all migraineurs, OR = 2
MWA, OR = 2.9
MWOA, OR = 1.6
44. Women’s Health Study
Prospective cohort study of 39,754 health
professionals ages 45 and older
No migraine or MWOA – no increased risk
MWA – Adjusted hazards ratio
1.53 for total stroke
1.71 for ischemic stroke
No increased risk for hemorrhagic stroke
Women < 55 with MWA had greatest risk:
1.75 for total stroke
2.25 for ischemic stroke
45. Stroke Risk: Low Dose OCs
Meta analysis of 16 studies (Gillum)
RR = 1.92 (1.4-2.7) controlling for
smoking and hypertension = 1
additional stroke per 24,000
Meta analysis of 14 studies (Baillargeon)
RR 1.84 (1.4-2.4) with low dose OC use
Also risk of 2nd and 3rd generation OC
use
46. Risk of Stroke Varies by Age:
Women
9 per 100,000 in 20-year-old MWA
3 per 100,000 in 20-year-old w/o migraine
80 per 100,000 in 40-year-old MWA
11 per 100,000 in 40 year-old w/o migraine
47. Summary of Risk
Migraine increases risk of stroke, OR = 2-3
Aura, female sex, age > 45, high
frequency, migraine duration – higher
risk > 12 attacks/year, > 12 years of
migraine)
OC increases risk of ischemic stroke,
OR = 2
OC increase risk of venous sinus
thrombosis, OR = 22
OC increase risk of subarachnoid
hemorrhage, OR = 1.6
48. Recommendations (ACOG, WHO, IHS)
Women with migraine should minimize
other vascular risks
Women with MWOA on hormone therapy
should stop if aura develops or
headache worsens
Women with migraine over 35 who smoke
should not use OCs
Women with a history of stroke or venous
clot should not use OCs
Controversy: Women with MWA should
not use hormonal therapy
49. Migraine and Cardiovascular
Disease (Women’s Health Study)
580 major CVD events occurred
Active MWA: hazard ratio 2.15 overall
1.91 for ischemic stroke
2.08 for MI
1.74 for coronary revascularization
1.71 for angina
2.33 for ischemic CVD death
18 additional major CVD events/10,000
women per year, after adjusting for age
MWOA: No increased risk
50. Migraine as a Clinically
Progressive Disorder
Episodic migraine evolves over time in
some patients, AKA “transformed
migraine”
Attacks increase in frequency (medication
overuse)
Chronic daily headache (>180 days yearly)
with superimposed migraine
Development of allodynia
51. Risk Factors for Development of
Chronic Daily Headache
Definition: Headache on more days than
not (> 15 days monthly X 3 months
Case-control, cross sectional population
study
Longitudinal follow-up for progression
800 people with episodic headache
3% developed CDH
6% developed 105-179 HA days
52. Predictors of Progression
Medication overuse
Especially OTC with caffeine
combinations, narcotic combinations,
barbiturate combinations
Weight: Overweight = 2X, Obesity = 5X!!
Baseline headache frequency (>1/wk)
Low socioeconomic status
Head injury
Lipton RB, Bigal M. Headache 2005; 45 (suppl 1) S3-S13
Goadsby PJ. Med J Austr 2005;182(3):103-4
54. Risk Factors and Development of CDH
Not readily modifiable Modifiable
Migraine as a disorder Attack frequency
(predisposition) Obesity
Female sex Medication overuse
Low SES Stressful life events
Head injury Snoring (OSA and
other sleep disorders)
55. Central Sensitization and Allodynia
Allodynia – a normally non-painful
stimulus becomes painful
Occurs in 75% of migraineurs during
migraine
Usually takes years to develop
56. Allodynia – Taking the History
Positive in 70%
Peripheral sensitization
Throbbing quality
Hair / eye glasses / earrings hurt
Hurts to touch: shave, sleep, wash
Central sensitization
Pain is worse with coughing, sneezing
Triptans less likely to work when central
allodynia is present
57. Implications for Treatment
Stratified care based on disability
Reduce environmental triggers, if present
Weight management
Investigate for sleep disorder when
appropriate
Prophylaxis
Reduce modifiable cardiovascular risk
58. Stratified Care by Overall
Disability
Little to none “Low end” Triptans
Moderate Combination treatments
Triptans Anti-emetics
Prophylaxis
Severe “High end” Triptans
Prophylaxis Narcotics
Anti-emetics Ergots
Refer to specialist
59. Summary
Women are different.
Migraines change
throughout the
reproductive cycle.
Estrogen is
important.
Migraine may be
progressive –
consider preventive
treatment.
60.
61. Additional Recommended Reading
Dodick DW. Chronic daily headache. NEJM
2008;354:158-165
Elliott D. Migraine and stroke: current
perspectives. Curr Pain Headache Rep
2008;30(8):801-12
Ferrante E, Tassorelli C, Rossi P, et al. Focus
on the management of thunderclap headache:
from nosography to treatment. J Headache
Pain 2011;12:251-258
Klein AM, Loder E. Postpartum headache. Int J
Obstet Anesth. 2010;19:422-30
62. Kurth T, Gaziano JM, Cook NR, et al. Migraine
and risk of cardiovascular disease in women.
JAMA 2006;296;283-291
Lipton RB, Bigal ME. Ten lessons on the
epidemiology of migraine. Headache
207;46(Suppl1):S2-S9
McGregor EA. Prevention and treatment of
menstrual migraine. Drugs 2010;70:1799-818
Sullivan E, Bushnell C. Management of
menstrual migraine: a review of current
abortive and prophylactic therapies. Curr Pain
Headache Rep 2010;14:376-84