How best to treat “Menstrual migraine”??
Migraine headaches are three times more common in women. Cyclic changes in estradiol and progesterone during the menstrual cycle modulate central neuronal activity and may cause a change in the incidence and intensity of headache. A trigger for menstrual cycle- associated migraine headache is thought to be a significant drop in blood estrogen levels that occurs during the 2-3 days prior to onset of menses. This hormonal mechanism is supported by the observation that the frequency of migraines in women increases considerably after menarche and during the perimenopause transition. Pure menstrual migraine (MM) is a headache event that occurs exclusively at the time of menses (8- 14% of all women migrainous ), while 60% of women may simply experience an increased migraine severity or frequency at menstruation (menstrually related migraine).
Women with recurrent migraine headache require a complete diagnostic evaluation to fully assess the presence of other headache disorders and other intracranial abnormalities. Consultation with neurologists who specialize in headache management is recommended to direct an optimal therapeutic approach.
Migraine headache is lateralized in 60% of cases, and is often preceded by premonitory symptoms (fatigue, nausea, sensitivity to light) for several hours or longer. Aura is a complex of neurologic symptoms (visual, sensory, motor, or speech disturbances) that may accompany migraines and typically precedes the onset of the headache. A prospective headache diary is essential in determining the timing of headache symptoms and their relationship to precipitating factors. Precipitating and exacerbating factors (besides estrogen withdrawal) include stress, worry, exertion, fatigue, lack of sleep, not eating, and certain foods containing nitrites, glutamate, aspartate, and tyramine. MM is usually not associated with aura even in women who have migraine with aura at other times. There is some evidence that MM attacks are longer, more severe, and more resistant to treatment than other migraines.
Menst diaries, similarly one can maintain diaries on Migraine too :-Patient diaries that record headache onset, relationship to the menstrual cycle events, and response to treatment will suggest MM. Because most MM attacks occur after ovulatory cycles, the predictability of menses permits a tailored use of prophylactic medications. The initial acute treatment of MM is the same as migraines that occur at other times. Triptan medications have been shown to be effective in relieving MM. If aura is present, triptans should be administered when the aura is over and the headache pain is beginning. Effective acute treatment of MM includes the administration of sumatriptan 50-100 mg or rizatriptan 10 mg. Combination therapy of a triptan with an NSAID (such as Mefanamic acid) is an option for women with both headache and menstrual symptoms.
Some patients may require preventative therapy for MM based on suboptimal response to an adequate trial of acute therapy. Preventative therapies for MM can be either nonspecific (those which do not address the hormonal trigger) or specific (hormonal strategies). Triptan treatment 2 days before anticipated menses and continued for 5 days has shown an up to 50% reduction in the number of headache events and their severity (sumatriptan 25 mg three times per day, naratriptan one mg twice daily, frovatriptan 2.5mg twice daily). One study indicated modest preventative benefit from naproxen sodium (550 mg twice daily) beginning 7 days before expected menses and continued for 13 days.
D caution!
Naproxen sodium :This benefit of naproxen sodium in the management of menstrual migraine should be balanced against the Food and Drug Administration warning of potential cardiovascular adverse events with the administration of naproxen sodium at higher doses. Current dosage recommendations for naproxen sodium are to not exceed 220 mg twice daily and for no longer than 10 days unless a physician directs otherwise. Oral contraceptive pills should not be administered to women who have migraine headache with aura at any time.
Hormonal prophylactic strategies that offset the premenstrual decline in estradiol may be effective for MM in women who do not respond to nonspecific treatment strategies. Continuous OCP administration for extended periods of time will suppress ovulation and menses. In the case of MM without aura, these cyclic headaches can be avoided for months at a time by the administration of continuous OCPs. The use of combined OCPs in women who have migraine headache with aura should be avoided. ACOG has concluded that the risks of OCPs outweigh the benefits in women over age 35 whose migraines are complicated by focal neurologic deficits, in women who have migraine without aura at all times, an extended-cycle OCP regimen may provide effective prevention. When using extended-cycle regimens that allow for periodic menses, estrogen supplementation is recommended during the placebo week. A 0.1 mg per day estradiol patch may be started 2 days before the placebo pills and will usually prevent MM.Some women who have contraindications to the use of oral contraceptives may still be candidates for targeted strategies using low-dose estrogen, such as the premenstrual Transcutaneous administration of estradiol (0.1 mg per day patch). Orally administered sublingual micronized estradiol ( 1 mg) has also been effective if given 48 hours prior to the anticipated onset of menstrual migraines and continued for 6 days. Estrogen supplementation should not be started prior to 6 days before the first full day of menstruation, with continuation into the first 2 days of menses, because rebound migraine may occur after the estrogen supplement is stopped.
GnRH agonists such as leuprolide acetate can markedly diminish MM. This salutary effect of GnRH agonists is not compromised by continuous estrogen and progestin add-back therapy at postmenopausal doses. GnRH agonists are not approved by the FDA for the management of MM. For this reason, the expense, and the hypoestrogenic side effects, GnRH agonist treatment for MM should be a last resort.
In summary, the initial treatment of MM should be the same as for migraine occurring at any time: a triptan administered early in the mild pain stage. If this strategy does not provide relief, preventative therapy with triptans, extended- cycle combined hormonal contraceptives, regular-cycle OCPs with supplemental estrogen, or targeted supplemental estrogen may be indicated. Nonhormonal options are necessary for women who have contraindications to estrogen and progestin use (such as MM with aura). The gynecologic physician should develop familiarity with the precautions and side effects of a given triptan medication, and should avoid prescribing triptans if other medications that interact with the serotonergic system (such as SSRIs) are needed (see the Caution box above about serotonin syndrome). An initial consultation with a neurologist specializing in migraine headache is recommended for the management of patients with MM.
No comments:
Post a Comment