Book Excerpt: The Woman's Guide to Managing Migraine

The following is an excerpt From: The Woman's Guide to Managing Migraine: Understanding the Hormone Connection to find Hope and Wellness, by Dr. Susan Hutchinson:

Case Study

Christy’s migraines are getting out of control, as are her periods, which are irregular and hard to predict. Now 47 years old, she has suffered from menstrual migraines since she was 15. Until 6 months ago, she was doing well taking naproxen beginning several days before her anticipated menstrual migraine; she took naproxen 550 mg twice a day for 7 days as a mini-preventive. She also took Imitrex (sumatriptan) 100 mg for acute treatment when she got a migraine; on occasion she self-injected with Imitrex 6 mg when a menstrual migraine was severe. However, she is now having so many headaches that she is running out of her nine Imitrex tablets a month that her insurance allows. She’s frustrated. She’s also noticing some insomnia and, on occasion, hot flashes. Her periods are anywhere from 2 weeks to 2 months apart. Her migraines have gotten worse because she is going through perimenopause.

Perimenopause and Migraines

Perimenopause is the time in a woman’s life when her ovaries “go crazy.” The estrogen and progesterone levels are all over the place as her ovaries are no longer producing the hormone levels on a regular schedule. Typically, the age of perimenopause begins in the 40s, usually between 45 and 50. It can last for 4—10 years but most often lasts from ages 47 to 51. Studies show that this is a time when migraines often worsen dramatically in women. Women who have a history of menstrual migraine or previous migraine exacerbation related to birth control pills, pregnancy, or postpartum are especially vulnerable to migraines getting worse during perimenopause. This would make sense as these are all times of hormonal change in women.

Does checking hormone levels make sense?

In some cases, yes. Checking estradiol levels, for example, can help determine if a woman is in perimenopause or menopause. An estradiol level is often ordered along with a follicle stimulating hormone (FSH) level. FSH is a hormone produced by the hypothalamus gland in the brain. The FSH level influences the ovary to produce estrogen. As a woman moves into menopause from perimenopause, the FSH increases and the estrogen level decreases. Testing through saliva has become popular; however, I prefer to measure hormone blood levels. It is always important to note where you are in your menstrual cycle, including the day of your last menstrual period, when any hormone level is checked. This can help physicians interpret the data properly.

Would estrogen be helpful for Christy? Is it safe? How should she take it?

To answer these questions, we need more information. We should find out if Christy needs birth control. If she has had a tubal ligation or her husband has had a vasectomy, then we may approach her treatment differently. Unfortunately, many women who are perimenopausal mistakenly assume that their chances of pregnancy are very low. Remember, though, that it only takes one egg to be released at ovulation to get pregnant. It is not uncommon for a woman in her late 40s or even early 50s to go to her doctor to be tested for menopause when she notices that she hasn’t had her period in 2—3 months. Surprise—she’s pregnant! Never assume, based on age or perimenopausal symptoms, that you do not need birth control.

If Christy doesn’t need birth control (for instance, if she had a tubal), here are some options for treatment:

  • Start taking a daily preventive such as Topamax (topiramate).
  • Consider herbal supplements and lifestyle changes.
  • Consider estrogen either as hormonal therapy (HT) or with low-dose contraception if she is healthy, has migraines with- out aura, or has no major risk factors for stroke or heart disease. (Note: If Christy is a smoker, or if she has uncontrolled high blood pressure, she should not take any form of estrogen.)

Finally, I would reassure Christy that there is “light at the end of the tunnel” in that her migraines may go away or get much less intense when she is menopausal. Doctors and patients need to aggressively treat migraine during perimenopause because of the woman’s fluctuating hormone levels (which wreak havoc on migraines), and a patient may feel as if she needs to take more medication that she would like. But she should keep in mind that she will not have to take these medications for the rest of her life. Christy’s migraines will improve in the future.

Excerpt From: Susan Hutchinson, MD. The Woman's Guide to Managing Migraine: Understanding the Hormone Connection to find Hope and Wellness, 2013, Oxford University Press (New York)

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