Definition and Overview
Migraine is a neurological disease that shows representative gender differences. Before puberty, the prevalence is similar for men and women, but after puberty, the prevalence increases rapidly in women, reaching about 18%, which is three times that of men (about 6%). The main cause of this gender difference is cyclical fluctuations in estrogen levels.
Hormonal changes according to a woman's life cycle (menarche, menstrual cycle, pregnancy, lactation, menopause) directly affect the occurrence, worsening, and improvement of migraines.
Hormones and migraine mechanisms
Estrogen Withdrawal Hypothesis
Migraine attacks are triggered by a rapid drop in absolute levels of estrogen. A sharp drop in estrogen before menstruation causes changes in serotonin receptor sensitivity, increased CGRP (calcitonin gene-related peptide) secretion, and trigeminal nerve sensitization, triggering migraines.
Prostaglandins
During menstruation, large amounts of prostaglandins E2 and F2α are secreted from the endometrium, which contributes to systemic vascular responses and pain sensitization.
Menstrual-related migraines
definition
According to the International Headache Society (ICHD-3) classification, it is divided into two types.
- Pure menstrual migraine: When attacks occur only on day -2 to +3 of the start of menstruation, and there are no migraines at other times. Approximately 7-10% of all migraines in women.
- Menstrually related migraine: When attacks occur during menstruation but also occur at other times. About 50-60%.
Features
Compared to non-menstrual migraines, menstrual-related migraines tend to have more intense attacks, longer durations (about 72 hours on average), and similar initial response rates to triptans but higher recurrence rates.
acute care
- Triptans: sumatriptan, rizatriptan, etc. It is effective in the early stages of menstrual migraine attacks.
- NSAIDs: Naproxen, ibuprofen. It has an auxiliary effect by suppressing prostaglandin production.
- Triptan + NSAID combination: Sometimes more effective than use alone.
mini-prevention
In patients with regular menstrual cycles, short-term prophylaxis is administered from 2 to 3 days before the expected menstrual period until the end of menstruation.
- frovatriptan: Strongest evidence for preventing menstrual migraine. Administer once or twice daily.
- Naproxen (naproxen sodium): 550 mg twice daily
- Estrogen supplementation: Start premenstrual with a transdermal estradiol patch (100 μg) to alleviate estrogen withdrawal.
Oral contraceptives and migraines
migraine without aura
Estrogen-containing combined oral contraceptives (COCs) can be used, but should be monitored for worsening migraines. Shortening the placebo period or continuous dosing may reduce migraine frequency.
Migraine with aura
In patients with migraine with aura, estrogen-containing COCs significantly increase the risk of ischemic stroke. According to a consensus statement from the European Headache Society (EHF) and the European Society for Contraception and Reproductive Health (ESC), the use of COCs in patients with migraine with aura is generally contraindicated. Progestin-only preparations (minipill), copper intrauterine device, and levonorgestrel intrauterine device are recommended as alternative contraceptive methods.
Pregnancy and Migraines
progress during pregnancy
Because estrogen levels remain stable and high during pregnancy, migraines improve in approximately 60 to 70 percent of women, especially during the second and third trimesters. However, in approximately 4 to 8% of cases, migraines may occur for the first time or worsen during pregnancy.
treatment during pregnancy
Because there are significant restrictions on drug use, non-drug treatment is priority.
- Non-pharmacological treatments: regular sleep, stress management, trigger avoidance, relaxation training, biofeedback.
- Acute treatment: Acetaminophen (first line), sumatriptan (as indicated, no evidence of increased risk of malformations)
- Contraindications: Ergotamine, valproic acid, topiramate (teratogenic)
- Preventive treatment: propranolol (starting in the second trimester), magnesium (400-600 mg/day)
Treatment during lactation
Sumatriptan can be used during breastfeeding because it passes into breast milk only in small amounts. Ibuprofen is also safe. Ergotamine and aspirin (high doses) are contraindicated.
Menopause and Migraines
menopause transition
During perimenopause, migraines often worsen due to increased estrogen fluctuations. Both headache frequency and intensity may increase.
after natural menopause
As estrogen levels steadily decrease, migraines improve or disappear in approximately 60 to 70 percent of women. However, in some cases, it persists even after menopause.
Hormone replacement therapy (HRT)
Because oral estrogens can worsen migraines, transdermal estradiol (patch, gel) is preferred in migraine patients. Continuous administration is more beneficial for migraine than periodic administration.
surgical menopause
Surgical menopause caused by bilateral oophorectomy results in a rapid drop in estrogen, and unlike natural menopause, the rate of worsening migraines is high. For migraine patients who require surgical menopause, advance planning for hormone supplementation is necessary.
Summary of Treatment Strategies
Treatment of migraine in women requires a customized approach that takes into account hormonal status according to the life cycle. Key elements include short-term prevention based on the menstrual cycle, checking for signs when choosing a contraceptive method, selecting safe medications during pregnancy and lactation, and managing menopausal hormones.