Transcript Migraine and Hormonal Problems in Women

An Update on Managing
Migraine in Women
Kay kennis Nov 2012
Outline
• Topiramate in women of child bearing age
• Menstrual migraine
• Migraine and the use of combined
hormonal contraceptives
• Migraine in pregnancy and lactation
• Migraine, the menopause and HRT
Topiramate in Women of Child
Bearing Age
• Advice from CEU (FSRH) Jan 2012 (NICE more
conservative)
• Weak enzyme inducer. If dose > 200mg / day and long
term (>2 months use) then CHC and POC contraindicated
• Ideally change to depot or coil (IUD and IUS ok)
• Could use 2 COC pills (eg 20 and 30mcg) plus extended
or tricycling regimen with pill-free interval 4 days
• Emergency contraception – Cu-IUD best if within 120
hours UPSI or within 5 days expected ovulation.
Otherwise use 2 x 1.5mg LNG if within 120 hours
(outside product license). Ella One can’t be used with
enzyme-inducing drugs
Menstrual Migraine
• 20-60% of women report some association
• Menstruation is risk factor for migraine
without aura (even if woman also has
attacks with aura at other times)
• Oestrogen withdrawal in late luteal phase
• No extra migraines at ovulation in trials
• Attacks more severe, longer lasting and
less responsive to treatment
Management
• Standard diet and lifestyle modifications
and avoid triggers
• Standard acute treatment (? Mefenamic
acid – supported by trials)
• Prophylaxis:Use diary to confirm diagnosis
– if frequent non-menstrual attacks in addition
to menstrual migraine standard prophylactics
best
– Perimenstrual prophylaxis needs regular
periods and predictable migraine
Perimenstrual Prophylaxis
• None licensed as evidence limited
• Try for 3 cycles before abandoning
• 1st line (??) NSAIDs (esp if
dysmenorrhoea/ menorrhagia). Remember
contraindications and consider PPI cover.
• Perimenstrual triptans (most robust
evidence)
• Perimenstrual oestrogen supplements
• Contraceptive strategies
NSAIDs for menstrual migraine
• Some migraine thought secondary to
prostaglandins released from
endometrium during menstruation
• NSAIDs are prostaglandin inhibitors
• Particularly useful if menorrhagia /
dysmenorrhoea
• Evidence for naproxen 500mg od (or
550mg bd used prophylactically)
Perimenstrual Triptans
• Disadvantages
– Increased cost
– No trial showing better efficacy than standard
regimens
– Safety
– Limited choice of abortive therapy for break through
• BUT did have more robust evidence
• Frovatriptan (2.5mg bd) or zolmitriptan (2.5mg
bd – tds)
– Take from day -2 for 6 days
– May cause rebound headache
Perimenstrual Oestrogen
Supplements
• Prevent oestrogen dip
• Contraindicated if H/O oestrogen dependent
tumour or thromboembolism
• Only useful if menstruation regular and
predictable (though could use fertility monitor to
start Rx 10 days after ovulation)
• Oestradiol gel 1.5mg daily from day -2/3 for 7
days
• Alternative 100mcg 7 day patch
• Problem is delayed migraine after withdrawal
(could extend to day 7 and taper dose last 2/7no trial evidence)
• RARELY used even by specialist in tertiary clinic
Contraceptive Strategies
• Useful if woman also needs contraception
• Additional non-contraceptive benefits on premenstrual
syndrome, menorrhagia and dysmenorrhoea
• Ok even if cycles irregular
• Can’t use if aura
• Options
– Tri-cycle COC (not if aura)
– Extended regimens (see next slide)
– ?Depot- should provide stable low levels of
oestrogens but no studies (other PO methods too low
dose to suppress oestrogen fluctuations)
Extended Combined Hormonal
Contraceptive Regimens
• Cochrane review found extended regimens are
a reasonable approach to CHC use though still
off licence
• Women can eliminate frequency of withdrawal
bleed and any associated symptoms eg
migraine
• Strategies include
– 3 weeks CHC use with 4 day break (better
than 7 day break as lower pregnancy risk)
– Continuous use until break through bleed then
4 or 7 day break (4 thought safest)
Choice of Contraception in
Migraine
• CHC contraindicated if aura
• Aura and CHC are independent risk
factors for stroke- synergistic. Stroke risk
in pt with Migraine aura increased from 4.4
to 8.5/100,000 by CHC. To 34.4 if smoker!
• If migraine without aura same cautions as
rest of population
Migraine in Pregnancy
• Migraine without aura most likely to
improve in pregnancy
• Management in pregnancy is essentially
similar to management during nonpregnant state
• Women benefit from early advice on drugs
• Try and minimise- ok to reassure meds
taken are unlikely to have caused harm,
but don’t recommend unnecessarily
Medication in Pregnancy
• Acute
– Paracetamol 1st choice
– Aspirin and ibuprofen (up to 600mg /day) ok
to 30 weeks (AVOID aspirin in lactation)
– Cyclizine and promethazine first line antiemetics (metoclopramide reverses gastric
stasis so can have dal benefit)
– Sumatriptan indicated if above fail- data
reassuring
Medication in Pregnancy
Continued
• Prophylaxis
– 1st line – Propranolol (lowest effective dose). Possible
increased congenital heart defects, intrauterine
growth retardation, low birth wt – but may due to
underlying maternal condition. Some evidence of
neonatal bradycardia, hypoglycaemia, hypotension,
respiratory distress. Data on stopping 24-48H before
delivery conflicting.
– 2nd line – Amitriptyline (10-25mg). Aim to stop 3-4
weeks before delivery- antidepressant doses can
cause tachycardia, irritability, muscle spasm and
convulsion
Emergency Treatment in
Pregnancy
• 2 cases of prolonged migraine aura
successfully treated with IV
prochlorperazine (10mg over 8 hours) plus
1mg magnesium sulfate over 15mins
• 6 day reducing course of steroids (60mg,
40mg, 20mg 2 days each) could be
considered for long duration attacks, but
not suitable for repeated use in pregnancy
Red Flags in Pregnancy
• Hypertensive disorders of pregnancy and stroke
are more likely to occur in women with migraine
• Beware of new neurological symptoms or signs,
rising BP, known risk factors for pathology or
new aura
• Secondary headache more common in
pregnancy include eclampsia, stroke, post dural
puncture, cerebral angiopathy, pituitary apoplexy
and cerebral venous sinus thrombosis
If woman develops aura for first
time in pregnancy consider
• Imminent eclampsia
• Cerebral venous sinus thrombosis
• Thrombocytopenia
• May be migraine but needs admission for
further investigation
Management of Migraine in
Lactation
• Similar precautions to pregnancy (but
don’t use aspirin)
• Breast feeding generally sustains the
benefit of pregnancy on migraine
• If anti-emetics required metoclopramide
and domperidone increase breast milk
production so could have dual benefit
• Contrary to prescribing information data
support use of sumatriptan in breast
feeding without disruption (if necessary)
Management of Perimenopausal
Migraine
• Optimise vascular risk factors in all women with
migraine. Women’s Health Study (5125 women)
shows active migraine with aura is a risk factor
for CVA and CVD. The risk for CVA is modified
by age, with greatest risk age <50
• Maintaining a stable oestrogen environment can
benefit oestrogen withdrawal migraine and is the
most effective treatment for vasomotor
symptoms (see next slide)
• Good prognosis after menopause for pts with
perimenopausal exacerbation
Using HRT in Perimenopausal
Migraine continued
• Migraine with aura is not a contraindication to HRT
• If aura appears for first time after starting HRT exclude
TIA / other migraine mimic and reduce or stop oestrogen
• Patches and gels better in migraine (more stable
hormone levels than tabs)
• Be cautious if perimenopausal and intact uterus- but
continuous oestrogen with Mirena protection is better
tolerated in migraineurs than cyclical combined Rx (also
good if contraception required)
• Use lowest effective dose of oestrogen
• Tibolone best if oral needed
Alternatives to HRT in
Perimenopausal Migraine
• Fluoxetine and venlafaxine – may increase
migraine in first few weeks
• Gabapentin
• Neither are as effective as HRT for the
vasomotor symptoms but may help
References
• MacGregor Headache in Pregnancy
Neurol Clin 2012.pdfMacGregor
• Perimenopausal migraine in women with
vasomotor symptoms Maturitas 2012.pdf
• MacGregor Progress-in-thePharmacotherapy-of-MenstrualMigraine.Clinical Medicine InsightsTherapeutics 2011.pdf
Summary
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Topiramate and contraception
Menstrual Migraine
Migraine and contraception
Migraine in pregnancy and lactation
Migraine in the perimenopause
• Any Questions?