Healing Hormonal Headaches from Menarche to Menopause

Migraines accounted for 4 million emergency department (ED) visits overall in 2016 in the U.S., and headache was the third most common reason for ED visits in females 15–64. Understanding the impact of hormonal fluctuations can help women stay ahead of the pain, according to one of the top headache specialists in the world.
“We have yet to fully comprehend the roles of biochemical, neurological, physiological, hormonal, genetic, and psychosocial aspects in migraine occurrences,” says Dr. Fred Cohen, Assistant Professor of Medicine and Neurology at the Icahn School of Medicine at Mount Sinai in New York and published headache researcher. “However we do know that hormones play a large role, as women have changes in their headache characteristics as they go through menarche (first period), menstruation, pregnancy, and menopause.”
Dr. Cohen notes that 21% of women suffer from headaches and migraines. Of those, it is estimated 50% of them have a greater risk of a migraine attack during their menstrual cycle. Estrogen seems to increase sensitivity to pain from both internal and external stimuli. It impacts how certain brain receptors respond to serotonin. When estrogen levels fluctuate, such as during the menstrual cycle pain pathways in the brain are activated, subsequently causing the release of inflammatory substances like prostaglandins, cytokines and calcitonin gene-related peptides (CGRP).
Hormone-related migraine attacks can be treated with oral contraceptives or estrogen replacement therapy. Additional preventative migraine treatments include anti-hypertensives, anti-depressants anti-epilepsy medications, onabotulinumtoxinA (Botox®), and CGRP monoclonal anti-bodies.
Lifestyle changes may be beneficial for controlling migraines, including proper sleep, healthy nutrition, regular exercise, and managing other migraine triggers such as stress and alcohol.
“Pregnant women may notice an increase in migraine attacks during the first trimester, but will then notice a decrease or even resolution of their attacks in the second and third trimester,” explains Dr. Cohen. “This is thought to be due to hormonal changes such as fluctuating estrogen and progesterone levels.”
Which treatment to use safely during pregnancy is a heavily debated topic in headache medicine. Many of the common migraine treatments, such as gepants and calcitonin gene related peptide (CGRP) monoclonal antibodies were not tested in pregnant women, and therefore have no evidence if they are harmful. Triptans raise theoretical concerns that they interact with placenta. Botox®, a common treatment for chronic migraine, is cautioned out of fear that the treatment crosses the placenta and affects the fetus. However, recent studies have reported there have not been any increase risk of pregnancy complications associated with Botox® treatments for chronic migraine.
“Personally, I commonly treat severe headaches and migraine in pregnant patients with nerve blocks,” shares Dr. Cohen. “A nerve block is a procedure I perform in my office that entails injecting lidocaine (a numbing agent) around nerves on the head. This provides relief for the patient, and has evidence that it does not affect the fetus.” 
Acetaminophen (Tylenol) has long been an over-the-counter staple treatment given to pregnant women who suffer from migraine and headaches. Recently, there was a study published raising concern for the use of acetaminophen in pregnant women.
“On the other side of the argument, not treating a pregnant patient's severe headache/migraine at all can cause serious stress, and that too can harm the fetus,” says Dr. Cohen. “Ultimately, each patient's presentation should be discussed with a headache specialist and obstetrician to determine the risks and benefits of each treatment.”
As women move past their child-bearing years, data suggests they have stable to increasing numbers of migraine attacks in perimenopause, then a decreasing number of attacks after menopause. Most patients are still treated with common migraine treatments, but in cases that are heavily suggested to be related to a decrease in estrogen, estrogen replacement therapy may be offered.
For more information visit Dr. Cohen’s website and follow him on Twitter, Instagram and TikTok.
About Dr. Fred Cohen
Fred Cohen, MD, is one of the few headache specialists in the U.S. trained in both Internal Medicine and Headache Medicine. Based in New York, NY, the world-renowned Headache Specialist is Assistant Professor of Medicine and Neurology at the Icahn School of Medicine at Mount Sinai. ​Dr. Cohen is Assistant Editor of Headache: The Journal of Head and Face Pain and Current Pain and Headache Reports. His research and expertise have made him a highly sought after presenter at headache conferences around the world. For more information visit www.fredcohenmd.com.
Submitted by Hartford, CT

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