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When Migraines Strike ...
Although prevention is very effective in managing this disorder, only 3 percent to 5 percent of women seek preventive therapy.
To better understand this issue and provide guidance for physicians treating female migraine patients, physicians at the Mayo Clinic's Arizona Women's Health Internal Medicine section reviewed all the major studies on the disorder published in the past five years. They compiled study results into a concise review for clinicians, published in last month's issue of the Mayo Clinic Proceedings.
"Most people with migraines first seek help from their primary-care provider instead of a neurologist or a specialist. The purpose of our paper is to provide more information for primary-care physicians who typically manage these cases," says Beverly Tozer, M.D., who led the review.
The review emphasized preventive therapies for migraines at different stages of a female's life. According to Tozer, strong evidence suggests that hormonal changes effect migraine development, with migraines being most prevalent during the reproductive years.
"Almost one-fourth of women in their reproductive years experience migraines," says Tozer. "During these years, women are building both their families and their careers. The predominance of this disorder in women with its associated social, functional and economic consequences makes migraine an important issue in women's health."
Approaching the issue with regard to hormonal causes, the Mayo authors tracked migraine development and treatment for women from childhood to menopause.
· Childhood and Adolescence: Research found that in children ages 4 to 7, girls are less likely than boys to suffer from migraines. However, by puberty, girls are three times more likely than boys to have migraines. Stress is a major migraine trigger for children and adolescents, and stress management techniques have helped children as young as 8 years old.
If other therapies and lifestyle changes fail to reduce migraines, researchers have found that cyproheptadine is a useful medication for children under 6, with several other preventive medications available to older children.
As many as one-third of all pediatric migraine patients require periodic courses of daily preventive medication.
· Reproductive Years: Menstruation is one of the most common migraine triggers. Menstrual migraines are typically migraines without aura (bright flashing lights that may precede migraine) that occur predictably around the menses. They are caused, studies suggest, by the decline in estrogen levels before menstruation.
Menstrual migraines may be prevented by taking medication only during the vulnerable period when migraines are expected to occur.
Medications used in the prevention of menstrual migraine include nonsteroidal anti-inflammatory drugs, ergots, alkaloids and triptans. Medications used in the prevention of other migraines also are effective in preventing menstrual migraine.
In some patients, menstrual migraines may also be managed with hormonal manipulation using oral contraceptives.
However, reviewers emphasized that oral contraceptives should not be prescribed in migraine patients who smoke because of the dramatic increased risk of stroke.
· Pregnancy: Pregnant women with migraines often have fewer attacks by the end of the first trimester. According to the studies, 50 percent to 80 percent of women noted a decrease in attacks, while a smaller percentage experienced a worsening or onset of attacks.
The reviewers noted that pregnant women should avoid using any medication, except in the most severe cases.
If it is determined that the benefits of preventive therapy outweigh the risks to both mother and fetus, medications such as propranolol hydrochloride, verapamil hydrochloride and topiramate may be used. However, valproic acid, divalproex sodium and ergot derivatives should never be prescribed to pregnant patients.
· Menopause: Changing hormone levels make the menopausal transition challenging for many women with migraines. Studies found that hormonal manipulation and long-cycle usage of low-dose oral contraceptives have been useful in managing these migraines.
Migraines beginning after age 65 are extremely uncommon and warrant further evaluation. Physicians should be aware that as many as one-third of all headaches in elderly women are due to secondary causes. Doctors recommend lower doses of all preventive medicine for this group to avoid side-effects.
Medication should also be selected with consideration to other health conditions.
The authors of this review article believe preventive therapy could benefit many women with severe migraines. Before beginning treatment, however, they recommend trying nonpharmacological preventive strategies first, such as getting regular and plenty of sleep and exercise, identifying and avoiding migraine triggers and incorporating relaxation techniques.
However, if some or all of these attempts fail, they believe preventive medicines can help improve conditions for many of these women.