Migraine Headaches: A Real Pain for Women
Jason P. Krutsch, M.D.
Director, Interventional Pain Management
Associate Director, Pain Fellowship
Associate Professor, Department of Anesthesiology
University of Colorado Denver School of Medicine
Migraine Headache
Seventy-six percent (76%) of women report at least one
significant headache per month, and over 90% have
experienced a migraine headache in their lifetime. Migraines
are three times more common in women than men; it is
estimated that one in six women suffer from migraine
headaches. Migraine sufferers frequently have family
members that suffer from regular headaches.
Migraine headaches usually involve one side of the head at
a time, are described as pulsating in nature, interfere with
daily activities and are aggravated by routine movements.
Headache attacks last 4-72 hours and are often
accompanied by nausea, vomiting, and light or sound
sensitivity.
Pain in the back of the head and neck, and sinus pain/pressure are common during
migraine attacks and often lead to a misdiagnosis of tension-type headache or sinus
headache.
Migraines include a large number of headache presentations, and are divided into
two major categories: with aura (classic migraine) and without aura (common
migraine). Auras are symptoms that may precede, accompany or follow the
migraine. These may include visual disturbances, facial or arm weakness or tingling,
and language disturbance. An aura can be an unusual visual, olfactory, language or
other sensory experiences that are a sign that the migraine will soon occur.
Chronic migraine is defined as headaches that occur on more than 15 days per
month of which at least 8 headache days must meet the diagnosis of migraine
without aura and/or respond to migraine-specific drugs.
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Triggers of Migraines
Genetic and environmental factors predispose patients to attacks. Common triggers
of migraines include: stress, hormonal changes (menstrual periods, oral
contraceptives, early pregnancy), missing meals, sleep (too much or too little),
certain foods (aged cheese, chocolate, and alcohol), weather changes, smoking, and
strong odors.
Principles of Treatment
There are two strategies for treating migraines: prevention of attacks (preventive)
and treating individual attacks (abortive). Avoiding triggers and utilizing stress
management techniques, along with improvement of general health can be helpful in
preventing migraine headaches. Many doctors will ask patients to keep a monthly
headache log to identify triggers. Knowing what can trigger a migraine may help a
person avoid and prevent the migraine. Tools to help maintain a headache calendar
include:
 Paper diaries; www.achenet.org/tools/diaries/index.asp
 Electronic diaries and apps: for iphone and blackberry apps visit
http:www.iheadacheapp.com
Preventive Therapy
Medications that are used to prevent migraine headaches include: supplements
(magnesium, butterbur, CoQ10), beta-blockers, anticonvulsants, antidepressants,
lidocaine nasal spray and calcium channel blockers.
Botulinum toxin A (Botox) was approved by the Food and
Drug Administration in October, 2010 for the prevention of
migraine in adults. Botox is injected in numerous sites in
the face, head and neck and has been shown to
significantly reduce the number of migraine attacks in some
patients. The beneficial effect may last up to 90 days after
injection. Botox has been found to relieve pain in a variety
of conditions, including migraine. Although the exact
mechanism of Botox pain prevention is not fully
understood, studies indicate that it prevents the release of
inflammatory chemicals from pain nerves. Blocking the
release of these substances can reduce pain signals that
cause migraine. Botox injection into the face, head and
neck is performed routinely every three months as
preventive treatment for chronic migraine. This can safely
be repeated and has few side effects. Since FDA approval for its use to treat
migraine, Botox therapy is covered by health insurance if certain clinical parameters
are documented. Typically it is not a first line treatment for migraines however if
headache frequency persists and other treatments are not successful your doctor can
discuss Botox as an option and justify the payment of treatment with your insurance
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company. The doctors at The University of Colorado Hospital Pain Clinic are experts
in the use of Botox as a preventive treatment for migraine.
Abortive Therapy
There are few means of reversing a migraine attack without medication. Actions that
can be taken include applying ice, practicing relaxation and biofeedback techniques,
sleeping.
Migraines can be treated after an attack begins using so-called “abortive therapies”.
Triptans are effective at treating individual headaches but do not provide preventive
treatment. Commonly used Triptan medications include Frova, Relpax, Imitrex,
Maxalt, Zomig, and Amerge. The Non Steroidal Anti-Inflammatory Drug (NSAID)
category includes ibuprofen, indomethacin, and acetaminophen. Also, caffeine, nerve
blocks, anti-nausea medications, corticosteroids (prednisone) and rarely narcotics
are used to treat migraine headaches.
Rebound Headaches
The chronic use (averaging 3 times or greater per week) of any of the triptans,
NSAIDs, acetaminophen, and narcotics can lead to medication overuse, or rebound,
headaches. These medications should not be used more than twice per week over an
extended period of time. If a migraine sufferer requires analgesics regularly, they
should be offered prophylactic therapy.
Treatment of Menstrual Migraine
Menstrually related migraines are defined as headaches that occur between two days
before and two days after the onset of menses in at least two of three menstrual
cycles and additionally at other times in the cycle. Pure menstrual migraine is
defined as headache occurring exclusively on the day of the onset of menses or the
following day in at least two of three menstrual cycles and at no other times of the
menstrual cycle.
The treatment of menstrually related migraine and pure menstrual migraine consists
of acute therapy at the time of the migraine and preventive therapy perimenstrually
for several days to prevent the migraine. The same treatment goals, principles, and
medications used for the acute treatment of nonmenstrual migraine apply to the
treatment of menstrually related migraine. For patients with a suboptimal acute
treatment response or whose attacks continue to recur over several days despite an
initial response to acute medication, short-term migraine prevention may be useful.
Predictable menstrual periods and a predictable relationship between the onset of
migraine and menses are important for this strategy to succeed. Treatment usually
begins two days before the onset of menses or one day before the expected onset of
the migraine in relationship to the onset of menses; treatment is continued for five
to seven days. Medications that are used and for which there is evidence of efficacy
include naproxen sodium, mefenamic acid, frovatriptan, naratriptan, and
percutaneous estradiol.
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Treatment of Migraine during Pregnancy
Behavioral management of headache, including relaxation training, biofeedback
training, and cognitive behavioral therapy, should be recommended as a standard
treatment for all women with migraines who are pregnant or planning pregnancy.
Although drug therapy should be avoided during pregnancy, migraine may worsen
during the first and second trimesters, and pharmacologic therapy is, therefore,
unavoidable for some women. Intermittent acute treatment may be sufficient, but
preventive medications may be necessary for women who have severe daily or neardaily migraine. Patients should be informed of any known possible treatment-related
adverse pregnancy outcome associated with a particular medication and told that
definitive information about the safe use of many drugs in pregnancy is lacking.
The U.S. Food and Drug Administration (FDA) has five categories of labeling for drug
use in pregnancy. An alternative rating system is the Teratogen Information System
(TERIS), a resource based on a thorough review of published clinical and
experimental literature. The American Academy of Pediatrics (AAP) has also reviewed
and categorized drugs for lactating women.
Birth control pills and Migraines
Recent evidence from the Women’s Health Study shows an increased risk of ischemic
stroke in apparently healthy women older than 45 years who have migraine with
aura when compared with unaffected women.
The World Health Organization recommends that women who have migraine
without aura and are age 35 years or older and women who have migraine
with aura at any age should not use combined (estrogen-progestin) oral
contraceptives.
Links for more information:
www.nlm.nih.gov/medlineplus/migraine.html
If you are interested learning more about the services of Pain Care at the University
of Colorado Hospital, including the treatment of migraines, please contact your WISH
doctor for a referral. She can help connect you to Dr. Jason Krutsch and the
expertise at University of Colorado Hospital. Or call directly 720-848-1970.
About the Doctor
Jason P. Krutsch MD,
Director, Interventional Pain Management
Associate Director, Pain Fellowship
Associate Professor, Department of Anesthesiology
University of Colorado, Denver School of Medicine
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Dr. Krutsch is an Associate Professor of Anesthesiology and Director of Interventional
Pain Management at the University of Colorado, Denver. He received his M.D. from,
and completed his residency in Anesthesiology at University of Colorado. He received
pain management and neuromodulation fellowship training at the Barolat Institute
and the University of Colorado. Dr Krutsch is the site director of the Anesthesiology
Pain Medicine Fellowship. His pain management interests include spinal cord and
peripheral nerve stimulation, radiofrequency, vertebroplasty, headache, spine pain
and cancer pain. Dr. Krutsch manages the most complicated pain cases in the
region. Offering patients a comprehensive and multi-specialty team approach to
solving pain problems. He and his team are constantly studying new techniques for
treating and managing pain.
For more information about The Women’s Integrated Services in Health (WISH)
Call 720-848-9474 or go to www.wishforwomen.org
Your WISH team can help make a referral to
The Pain Service at University of Colorado Hospital
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