Migraine treatment and prevention in women
ROCHESTER, Minn. -- Migraines are more common in the United States than diabetes, osteoarthritis or asthma. Of the 28 million people who experience migraines in this country, 18 million are women. 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, Mayo Clinic in Arizona Women's Health Internal Medicine physicians 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 the August 2006 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 Dr. 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," Dr. Tozer says. "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 have 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.
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.
Menstrual migraine -- Migraines increase substantially after menarche. 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 also may 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 medication except in severe cases.
If it is determined that the benefits of the 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.
Early 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.
Late menopause -- Migraines beginning after age 65 is extremely uncommon and warrants 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 also should 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 sleep and exercise, identifying and avoiding migraine triggers, and using relaxation techniques. However, when these attempts fail they believe preventive medicines can help improve conditions for many of these women.
Others involved in this review include: Elizabeth Boatwright, M.D.; Paru David, M.D.; Deepa Verma, M.D.; Janis Blair, M.D.; Anita Mayer, M.D.; and Julia Files, M.D.
A peer-review journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 75 years and has a circulation of 130,000 nationally and internationally. Articles are available online at www.mayoclinicproceedings.com.
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