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It is National Migraine and Headache Awareness Month and time to understand hormonal migraines.

I reached out to Nina Riggins, MD, Ph.D., FAAN, FAHS, UCNS Diplomate, Neurologist, Headache Specialist, Director of the Headache and Traumatic Brain Injury Center, and Professor for Neurosciences at UC San Diego Health for some much-needed education on the subject.

Dr. Riggins explained that a migraine is not just a headache. It is a genetic neurologic disease, which is why when describing this type of headache we use “migraine”, not “migraines”. Migraine attacks are often triggered by changes that could include shifts in sleep schedules, weather, and hormonal changes. These hormonal changes can include estrogen levels around the menstrual cycle and perimenopause.

In addition to headaches, multiple brain networks can get involved, leading to many other symptoms. For example, you may not have a headache with a vestibular migraine but rather experience dizziness/vertigo.

Riggins said, “About 30% of people with migraine have migraine with aura. Visual aura is more common, but there are other auras, such as changes in speech, balance, and motor or sensory function. People with migraine with aura could be more predisposed to vascular complications such as stroke, especially if they take medications containing high estrogen doses. Smoking tobacco can increase the risk of stroke in women who live with migraine with aura and use estrogen. This is why a detailed discussion with your doctor on the risks and benefits of hormonal therapy needs to happen before the treatment.”

Your prescribing specialist needs to pay close attention to your particular health needs. Dr. Riggins says that she still sees older adults with increased intracranial pressure and daily headaches, possibly resulting from years of unnecessary testosterone intake by women.  She encourages headache specialists to work with endocrinology, women’s health, gynecologists, and primary care clinicians to help identify proper candidates for hormonal therapy and create individual treatment plans for each patient.

Riggins further explains that migraine attacks can be triggered by hormonal instability. As hormonal levels change during perimenopause, we often see an increase and worsening of migraine. Once levels of estrogen and other hormones are more stable, one can experience an improvement. Women who have had their ovaries surgically removed and are not put on estrogen therapy can experience migraine due to the sudden drop in estrogen.

What kind of doctor should a menopausal migraine sufferer see to address this?

“I believe in a multidisciplinary patient-centered approach. Talking to primary care and your neurologist about migraine is an excellent start. About 10% of the primary care visits are for migraine and headaches. This number shows the importance of collaboration of headache specialists and primary care clinicians.”

Can a high/low functioning thyroid bring on headaches and migraine attacks?

“Abnormal thyroid function can trigger a migraine attack and also can be a cause of a headache even on its own; an example could be a secondary headache due to inflammation of the thyroid, called thyroiditis.

In general, secondary causes of headache (due to other conditions) must be ruled out, especially in older adults with new or worsening neurologic symptoms. Stroke and other medical conditions should be carefully ruled out.”

If a migraine is hormonal, is it advisable to go on HT (hormone therapy) to balance your hormones to improve your migraine?

“Statistics show that 23 % of people can improve, 21 % can get worse on HT, and someone’s migraine might not change.

Because of that, HT is not the first line in migraine management, and when prescribed, formulations with a steadier release to provide stable levels of hormones in the body would be preferred. Transdermal delivery could be superior.”

Is there a difference in effectiveness between synthetic or bioidentical HT?

“We don’t have enough data on that yet, but we do have studies that showed that for migraine prevention in patients without aura, 100 mcg transdermal estradiol was more effective than lower doses.”

What non-pharmaceutical options will help with hormonal migraine:

  • “An anti-inflammatory diet can be helpful. A balanced diet is essential. Hunger can be a migraine trigger.
  • Lifestyle modifications can be helpful such as exercising at least three times a week and sleep hygiene.”

 Are there any helpful supplements such as ginger root, magnesium, B-complex, or Q10?? 

“Ginger could be a great treatment for nausea.  We have good evidence for using magnesium, CoQ10, and Vit B2 in migraine management. We recommend always consulting your doctor before starting any supplements.”

What are your thoughts on Botox for headache therapy? 

“Botox is FDA approved for people with 15 days or more of headache a month (chronic migraine). Many patients benefit from that treatment. It is 31 injections every three months. We don’t offer it to the patients with episodic, less frequent migraine.”

Are there any at-home electronics remedies that you can recommend?

“There are 5 FDA cleared devices for migraine treatment. They are contraindicated for a person with uncontrolled epileptic seizures and pacemakers, but generally, they are safe and could be very effective in managing migraine. FDA cleared devices include: transcutaneous supraorbital nerve stimulation, external combined occipital and trigeminal neurostimulation, single-pulse transcutaneous magnetic stimulation, remote electrical neuromodulation, and noninvasive vagus nerve stimulation.”

How do water and caffeine affect migraine?

“About 1 in 3 people with migraine report that dehydration triggers their migraine attack, so proper hydration is beneficial.

Caffeine can be used as a treatment for migraine and is a part of some over-the-counter migraine attack treatments. Excessive use of caffeine can lead to cardiovascular complications such as elevated blood pressure. Caffeine can lead to dehydration and insomnia (the half-life of caffeine is about 5-8 hours, so consuming it later in the day should be avoided). Abruptly stopping daily caffeine can lead to caffeine withdrawal headaches.” 

What about alcohol?

“Alcohol is a known trigger for a migraine attack, and we do not recommend it.” 

 Are there any foods or certain preservatives to try to avoid?

  • “Food which contains nitrates such as hot dogs and other processed meats can trigger headache by dilating vessels. (“Hot dog headache” is famous in the literature).
  • Some people might benefit from a diet diary, which helps determine if certain foods are triggering migraine.
  • I always trust my patients, and if someone feels that a low gluten diet works great for them, I support it. If someone without gluten sensitivity enjoys gluten-containing meals and reports that it is not migraine triggering, I will also support it.
  • The goal is to work together on best functioning and quality of life for our patients.” 

 Are there any new treatments on the horizon for migraine sufferers?

New classes of medications are coming. Examples are:

  • “Mambalgins are peptides from mamba venom. They suppress acid-sensing ion channels (ASICs) to relieve pain. There could be an exciting development in this direction in the future.
  • We are also working on biomarkers to identify the best treatment for each patient.”

Riggins is working with the American Headache Society First Contact Women’s Health Team to make more free resources available from headache specialists to the following doctors:  primary care, women’s health, gynecologists, maternal-fetal medicine, geriatrics, and all other clinicians.

Dr. Riggins thinks that research and education, along with patients and doctors working together, will make the future of headache medicine bright.  She leaves us with this parting message, “I hope patients with migraine and headache disorders will reach out to us, and there will be less pain in this world.”

Thank you, Dr. Riggins, for your generous time and for championing cutting-edge research. Congratulations to Dr. @NinaRiggins and her team for opening the UC San Diego Center for Headache and Traumatic Brain Injury!

My Motto:  Suffering in silence is OUT! Reaching out is IN! 

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