by Mark Miranda, Gazette Contributing Writer
 

Approximately 28 million Americans suffer from migraine headaches. Treating migraine headaches continues to be a challenge for the people who suffer from this disabling condition, and for the healthcare providers who treat these patients. The annual cost for the treatment of this condition in the United States is estimated to be at least $17 billion dollars.
Women are two times more likely to suffer from migraine headaches than men. Of these women, 60-70% have headaches with a menstrual relationship. While this association is widely recognized, it is not completely understood how hormonally associated migraines differ from non-hormonally related migraines.
Types of Migraines
There are two separate and distinct migraine entities associated with a woman’s menstrual cycle. The first condition is known as menstrually associated migraine, or MAM. This condition behaves more like muscle tension headache and is easier to treat. The pain is usually mild to moderate in intensity. This condition is usually seen just prior to ovulation and during a woman’s menses. The second type of migraine associated with a woman’s menstrual cycle is called menstrual migraine. The pain that is associated with this condition is often characterized as being “crushing and brutal” in nature. True menstrual migraine starts almost exclusively 2 days prior to the onset menses and can last up to the first three days of menses. This 5 day window, known as a menstrual window, is extremely resistant to any form of treatment. The trigger, or causative agent, for both of these types of migraine is caused by decreasing estrogen levels in a woman’s body.
Diagnosing
The diagnosis, of either of these conditions, is made through a thorough history of the patient’s migraine history, along with a complete physical exam. Critical to any evaluation and treatment plan for a patient is the use of a headache diary. This invaluable tool allows for tracking of the patient’s headache pattern, duration of the headache, and severity of the migraine pain. The diagnosis of hormonally associated migraine can be made simply by the patient’s history, physical exam, and headache diary.
Special imaging studies, such as CAT scans and MRI studies are only warranted when:
1. A patient complains that the headache pain is the worst pain ever experienced - often called “Thunderclap Migraine.”
2. The migraine pain is progressively becoming worse.
3. Pain that is one sided and is unrelenting.
4. Pain that is unresponsive to normal migraine therapy.
5. Migraine is associated with an abnormal neurologic finding such as slurring of one’s speech, or any loss of muscle strength.
Treatment
Successful treatment of women with either of these conditions is based upon the proper diagnosis and initiation of the appropriate medical therapy. The goal, if possible, is prevention. Successful treatment must be individualized. Aggressive management, by the healthcare provider, is essential to improve the quality of life for the individuals who suffer from these types of migraine.
Medical Therapy used to treat hormonally associated migraines:
I. Menstrually Associated Migraine (MAM). As stated previously, this type of migraine pain is not as debilitating as true menstrual migraine. In most cases, treatment for this condition would involve the use of birth control pills. This would give women an even level of circulating estrogen. Also, the use of non-steroidal anti-inflammatory agents such as Motrin, Aleve or Advil would be appropriate. Rarely are narcotics needed to treat this type of headache pain.
II. True Menstrual Migraine is an incapacitating medical problem. Once the migraine has started, it is almost impossible to break.
The development of a family of medications, known as the Triptans, Naratriptan (Amerge) and Frovatriptan (Frova) have been especially successful in treating, and in some cases, preventing this type of migraine. Long acting narcotics do play a minor role in the treatment of these patients. Long acting narcotics are best used in those patients as second line therapy. The long acting narcotics may be used when a migraine has become full-blown, and are used while the Triptan has had time to take effect.
Other classes of medications used to treat this condition include ergotamine derived medications such as Migranal and Sansert. Both are highly effective, but they have considerable side effects such as nausea and/or vomiting.
No single medication is completely side effect free. However, the development of triptans has given hope to 28 million Americans, especially 14 million women.