by admin | Jul 1, 2013 | Comorbidity
Stroke and Women
Women under the age of 45 who have migraine without aura may be at a slightly increased risk for stroke; women who have migraine with aura have more than twice the risk of heart attack or stroke than do women without aura or without migraine. This risk is further magnified if you smoke, have high blood pressure, or if you take oral contraceptives.
The relationship between migraine with aura and ischemic stroke before age 45 is well established, and there is also a relationship with TIA (transient ischemic attack) and subclinical lesions in the brain. The authors of the GEM study (Genetic Epidemiology of Migraine Study) noted: “There has been substantial literature confirming an association between migraine with aura and ischemic stroke before the age of 45. The question of whether there is a similar association with CHD before the age of 45 has not yet been definitively answered.”
It has been speculated that cortical spreading depression (CSD), which is presumed to be the basis of aura, could also predispose the brain to lesions, and possibly even stroke. Some researchers in the field think it possible that repeated episodes of CSD resulting in aura could be responsible for an increased risk of stroke.
The Reykjavik Study found that stroke occurrence was increased in men and women with migraine with aura, but that death due to stroke was only increased for men with migraine.
Meta-analyses of of studies of stroke in women with aura have determined that migraine confers a higher overall risk of both ischemic and hemorrhagic stroke. Migraine with aura in women confers an overall stroke risk of 4.3/1000, higher than either diabetes or obesity, and contributes as much risk as smoking or hypertension.
The CAMERA II study has shown that infarct size in stroke is 3.24 times larger in women with migraine with aura.
This underscores the necessity for women who have migraine with aura to control stroke risk factors as much as possible.
References:
1. Scher AI, Terwindt GM, Picavet HSJ, et al. Cardiovascular risk factors and migraine: the GEM population-based study. Neurology. 2005;64(4):614-620.
2. Schurks M, Rist PM, Bigal ME, et al. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ. 2009;339(oct27 1):b3914
3. Gudmundsson LS, Scher AI, Aspelund T, et al. Migraine with aura and risk of cardiovascular and all cause mortality in men and women: prospective cohort study. BMJ. 2010;341(aug24 1):c3966
4. Bigal ME, Kurth T, Hu H, Santanello N, Lipton RB. Migraine and cardiovascular disease. Neurology. 2009;72(21):1864 -1871.
5. Bigal ME, Kurth T, Santanello N, et al. Migraine and cardiovascular disease. Neurology. 2010;74(8):628 -635.
6. Eikermann-Haerter K, Lee JH, Yuzawa I, et al. Migraine Mutations Increase Stroke Vulnerability by Facilitating Ischemic Depolarizations. Circulation. 2012;125(2):335–345.
7. Palm-Meinders IH, Koppen H, Terwindt GM, et al. Structural Brain Changes in Migraine. JAMA. 2012;308(18):1889–1897.
by Christina Peterson, M.D.
updated 7-1-13
by admin | Jun 7, 2013 | Migraine
Do you ever delay treating your migraines?
It’s a fairly common thing to do. You think to yourself, this one won’t be all that bad. I’ll: eat lunch, have a cup of coffee, lie down for half an hour, drink a glass of water or diet soda—whatever thing you think might work that’s never really worked before. But you have hope. You have hope that this time you can beat this thing, this space alien invading your brain.
Why do we do this? I’ve done it myself. It never works. And yet, there is that hope that we can be in control, and not the migraine. I have a colleague who believes that this mistaken belief is part of the migraine itself, that there is cognitive confusion altering good decision-making because of the early stages of the migraine process. If we were thinking clearly, we’d just take our medication. I’m not so sure it’s that clear-cut, although that may be the case for some people. There are also issues of weighing out the risk-to-benefit ratios of whether the adverse effects of medication are worth the severity of this headache. There is also the issue of whether you have enough medication to last all month, and if this headache is “medication-worthy” in light of that.
“Masking the Pain”
I have also had patients tell me they did not want to treat their migraines because they did not want to mask the pain. Now, frankly, this does not make sense. About the only situation I can think of in which this might make sense would be a disaster setting in which one had sustained a head injury and needed to be monitored without benefit of a CT, MRI, or an ICU. Morphine would be withheld so that mental status could be monitored until you could be evaluated in a hospital setting.
However, there is no medical rationale for not taking migraine medication. It will not mask any damage being done to the brain unless your headache is due to something other than a migraine, and something serious at that, in which case you need to be in the emergency department anyway. So, unless you have the red flags that indicate a serious underlying problem, go ahead and take your migraine medication. You do not get points for suffering!
There is also evidence to suggest that early treatment of migraine not only ends an attack sooner, but prevents the pain from becoming fully established.
Red Flags in Headache
Red flags that indicate something serious other than a migraine might be occurring are:
- Significant fever with a headache (more than 99.5)
- Stiff-as-a-board kind of stiff neck
- Severe all-over muscle pains
- Headache that comes on like a thunderclap
- Worst headache of life
- Significant change in headache (not just it used to be on the right, and now it’s on the left – that’s actually okay)
- Any neurologic symptoms that are not part of your usual aura
If you have any of these, see your doctor or go to the emergency department for evaluation. It might not be anything serious, but better safe than sorry. And otherwise, treat your headaches. Unless you enjoy pain?
by admin | May 17, 2013 | Medication
Safety of Over-the-counter Medications
We all tend to think of over-the-counter medications as being safe. After all, regulatory agencies have allowed them to be over the counter. So, they couldn’t really be all that bad, could they?
Well, it turns out that they can—if you don’t take them properly. Some people have a tendency to think that they are safe, and that therefore, it is ok to take a few more painkillers than are recommended on the label. Some people have never actually read the label. (Have you?) And some people don’t realize that they are, in effect, getting a double dose of some medications, because one of the over-the- counter analgesics they are taking may also be a component of one of the prescription medications they are taking.
It’s important to read all labels and to avoid taking excessive amounts of over-the-counter medications. Follow the recommended amounts on the label unless your physician has specifically recommended something different. Too much anti-inflammatory medication, such as aspirin, naproxen sodium, or ibuprofen, can result in stomach irritation like gastritis, cause an ulcer, or promote gastrointestinal bleeding.
Be especially careful not to take too much acetaminophen (paracetamol). Doing so can be damaging to the liver. This damage can be magnified if you drink alcohol, even moderately. Liver damage can occur even in only 24 hours if 8 extra-strength acetaminophen caplets are combined with alcohol. At this time, more than half of all liver transplants are necessary because of the medical use of acetaminophen. Alcohol also increases the risk of gastrointestinal bleeding if combined with anti-inflammatory medications. Long-term overuse of some of these medications can also contribute to kidney damage.
Be safe—read the label, and don’t take medication in excess of the recommended amounts. Don’t combine acetaminophen, paracetamol, naproxen sodium, ibuprofen, ketoprofen or other anti- inflammatory medications with alcohol. Do remember that using over-the-counter medications more than three days a week can lead to medication overuse headache. And be aware that many prescription medications contain acetaminophen (paracetamol).
If your headaches are not responding to over-the- counter pain medication, see a doctor—more specific headache management will not only help your head, it may protect your liver, stomach and kidneys as well.
by admin | May 10, 2013 | Comorbidity
What is Rosacea?
Rosacea is a skin disorder causing redness, irritation, and sometimes, bumpy skin and acne-like breakouts.
Rosacea usually shows up between the ages of 30 and 50 or so. It occurs more commonly in women than in men, although affected men are more likely to experience more severe rosacea. Rosacea is also more common in the fair-skinned, especially those with Celtic or Scandinavian heritage.
The cause of rosacea is not known, but it is suspected to be due to a combination of genetics and environmental factors. In one study, 52% of rosacea sufferers had a family history of at least one family member with rosacea. People with rosacea are more likely to be infected with H. pylori (the bacteria causing ulcers). Those with the acne rosacea form of the disorder have been found to be more likely to react to Bacillus oleronius, which in turn causes overreaction of the immune system.
The Migraine-Rosacea Connection
A connection between migraine and rosacea was noted in 1976 by Tan and Cunliffe. In their study of 137 patients and 161 controls, 44% of the rosacea patients had suffered from migraine, as compared to 13% of the control group. Another Swedish study in 1996 with 809 subjects with rosacea found an overall rate of migraine of 14% as compared to 13% in the control group. However, they found a 27% rate of migraine in rosacea patients between the ages of 50 and 60, and proposed the possibility that hormonal changes were affecting both conditions.
Types of Rosacea
According to the American Academy of Dermatology, there are four types of rosacea:
- Erythematotelangiectatic rosacea – with symptoms of redness, flushing, and visible blood vessels
- Papulopustular rosacea, or rosacea acne – with symptoms of redness, swelling, and acne-like breakouts.
- Phymatous – with symptoms of skin thickness and a bumpy skin tecture.
- Ocular rosacea – with symptoms of red and irritated eyes, swollen eyelids, redness at base of eyelashes.
About half of rosacea sufferers indicate that their symptoms come and go.
Rosacea Triggers
Like migraine, rosacea has a variety of triggers. Some of the triggers between the two conditions overlap, although they are not identical. And also like migraine, not everyone has the same triggers.
The following are typical rosacea triggers:
- Hot beverages
- Alcohol
- Spicy foods
- A hot bath
- Stress
- Sun exposure – especially UVA
- Exposure to cold or humid weather
- Exposure to heat
- Exercise
- Topical creams or make-up
Treatment of Rosacea
The first step in the treatment of rosacea is trigger identification and lifestyle modification. In many cases, this is not sufficient, although it can be helpful. Skincare should include sunscreen, moisturizer, especially in cold weather, and avoidance of sunlight during midday. Many skin products or treatments can aggravate rosacea.
Medical treatment of rosacea can involve topical medications, short courses of antibiotics, and laser treatment.
It is important to see a dermatologist if you think you have rosacea, as the treatment will vary based on the rosacea type.
If you think you might have rosacea, here is a helpful rosacea quiz:
References:
1. Berg M, Liden S: Postmenopausal female rosacea patients are more disposed to react with migraine. Dermatology. 1996;193:73-74.
2. Tan SG, Cunliffe WJ. Rosacea and migraine. Br Med J. 1976;1(6000):21-21.
3. Wilkin JK. Flushing reactions: consequences and mechanisms. Ann. Intern. Med. 1981;95(4):468-476.
4. Spoendlin, Julia, Johannes J. Voegel, Susan S. Jick, and Christoph R. Meier.
Migraine, Triptans, and the Risk of Developing Rosacea: A Population-based Study Within the United Kingdom. Journal of the American Academy of Dermatology. http://www.jaad.org/article/S0190-9622(13)00308-3/abstract, accessed May 10, 2013.
Updated 5/10/2013
by admin | May 8, 2013 | Miscellaneous
What on earth is TRPV1? TRPV1 is an ion channel brain receptor – the long name is transient receptor potential vanilloid 1 (for you biology geeks). It is also known as the capsaicin receptor.
TRPV1 is activated by chemical irritants, inflammatory mediators, and physical mediators of tissue damage, like high temperatures and acid pH. The TRPV1 receptors are located in skin, tissues of the airways, gastrointestinal linings, and the outer coverings of the eye (cornea and conjunctiva). It has also been identified in various areas of the brain. It is thought to have a central role in neurogenic inflammation.
Although the functions of TRPV1 are still being identified, its role in central nervous system inflammation has made it a target for migraine research, as it may possibly play a role in causing hyperalgesia and allodynia. TRPV1 is thought to affect craniofacial pain via the trigeminal nerve system, in addition to other painful conditions. TRPV1 antagonists have been a target for drug development for various painful conditions, including migraine.
However, we already have an existing drug for migraine that has TRPV1 activity. Sumatriptan (Imitrex®, Imigran®, Sumavel®, Alsuma®) has been found to block the effects of capsaicin (the substance that makes chili peppers hot) on the trigeminal neurons in the brainstem. This confirms the role of TRPV1 receptors in the migraine process, and helps our understanding of migraine pathways. It may lead us to new therapies.
References:
1. Evans MS, Cheng X, Jeffry JA, Disney KE, Premkumar LS. Sumatriptan Inhibits TRPV1 Channels in Trigeminal Neurons. Headache: The Journal of Head and Face Pain. 2012;52(5):773–784.
2. Menigoz A, Boudes M. The Expression Pattern of TRPV1 in Brain. J. Neurosci. 2011;31(37):13025–13027.
3. Veronesi B, Oortgiesen M. The TRPV1 Receptor: Target of Toxicants and Therapeutics. Toxicol. Sci. 2006;89(1):1–3.
4. Meents JE, Neeb L, Reuter U. TRPV1 in migraine pathophysiology. Trends Mol Med. 2010;16(4):153–159.
by admin | Jan 5, 2013 | Comorbidity
Hypothyroidism and Headache
Hypothyroidism has been found to be associated with chronic daily headache* in both the varieties of chronic migraine and new daily persistent headache. In one study, 30% of individuals with hypothyroidism had developed mild daily headache within 1-2 months of onset of the thyroid disorder. A history of migraine predisposed to the development of headache.
Hashimoto’s Disease, an autoimmune form of chronic thyroiditis, has also been associated with increased likelihood of headache.
A study of white matter hyperintensities seen on MRI in migraine found that either hypothyroidism or hyperthyroidism (too low or too high) was associated with these MRI abnormalities.
* This was chronic migraine without any evidence of medication overuse.
References:
1. Moreau T, Manceau E, Giroud‐Baleydier F, Dumas R, Giroud M. Headache in hypothyroidism. Prevalence and outcome under thyroid hormone therapy. Cephalalgia. 1998;18(10):687-689.
2. Trauninger A, Leél-Őssy E, Kamson DO, et al. Risk factors of migraine-related brain white matter hyperintensities: an investigation of 186 patients. J Headache Pain. 2011;12(1):97-103.
by Christina Peterson, MD
updated January 5, 2013
by admin | Nov 14, 2012 | Comorbidity
Depression and Migraine
One of the most significant comorbid conditions associated with migraine is depression. This particular relationship is one that is considered bidirectional—it works both ways. What that means is that if you have a tendency toward depression, you are more likely to develop migraine headaches, but also if you are a migraine headache sufferer, you are more likely to become depressed. Careful population-based statistical studies have been done, and it does not look simply as if migraine headaches make you depressed, although that might seem a logical conclusion. It is not that simple.
Based on one of these large studies, a person is 2.9 times more likely to develop depression if they are a migraine sufferer, and a person is 3.8 times more likely to develop migraine if depressed.
Depression did not affect the frequency of migraine attacks, or the progression of migraine-related disability over time.
The situation is somewhat more significant for chronic daily headache, where the headache pain may have a more telling effect. Depression occurs in more than 80% of chronic daily headache sufferers. The comorbid depression often improves if the daily pain pattern can be broken, and an episodic pain pattern can be re-established.
If you suspect depression might be affecting you and your headache pain, discuss it with your physician. There are both medication and non-medication strategies available to help you cope.
references:
1. Jette N, Patten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders–a national population-based study. Headache. 2008;48(4):501-516.
2. Moschiano F, D’Amico D, Canavero I, et al. Migraine and depression: common pathogenetic and therapeutic ground? Neurol. Sci. 2011;32 Suppl 1:S85-88.
3. Tietjen GE, Herial NA, Hardgrove J, Utley C, White L. Migraine comorbidity constellations. Headache. 2007;47(6):857-865.
4. Hamelsky SW, Lipton RB. Psychiatric comorbidity of migraine. Headache. 2006;46(9):1327-1333.
5. Low NCP, Merikangas KR. The comorbidity of migraine. CNS Spectr. 2003;8(6):433-434, 437-444.
6. Moschiano F, D’Amico D, Canavero I, et al. Migraine and depression: common pathogenetic and therapeutic ground? Neurol. Sci. 2011;32 Suppl 1:S85-88.
7. Ligthart L, Nyholt DR, Penninx BWJH, Boomsma DI. The shared genetics of migraine and anxious depression. Headache. 2010;50(10):1549-1560.
by Christina Peterson, MD
updated Feb 7, 2010
by admin | Nov 10, 2012 | Comorbidity
While many IBS patients know that there are certain trigger foods that bring on their symptoms, there has never been a specific IBS diet. However, recent research suggests that there may be foods to avoid that can decrease your symptoms. Certain complex sugars can be the culprit in IBS.
What About Hot Chocolate and IBS?
Well, you can have the chocolate. However, dairy products may be an issue. In a lecture titled Food Choice as a Key Management Strategy for Functional Gastrointestinal Symptoms, Dr. Peter Gibson discussed his findings in the American Journal of Gastroenterology lecture. Dr. Gibson’s results indicate that following what is called the FODMAP diet can reduce symptoms within two days for some IBS sufferers.
FODMAP is short for “fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols.” It’s less important to remember these long chemical names than it is to know what foods they are in.
Oligosaccharides
- wheat
- rye
- onions
- garlic
- leeks
- scallions
- shallots
- artichokes
Galacto-oligosaccharides
Disaccharides
- milk products (except for hard cheese)
Monosaccharides
- excess fructose
- fruits that contain more fructose than glucose
- honey
- apples
- pears
- mangoes
- high frutose corn syrup
- agave nectar
Polyols
- sugar alcoholc
- sorbitol
- mannitol
- maltilol
- xylitol
- stone fruits: cherries, peaches, apricots, nectarines, plums/prunes
- watermelon
- apples
- pears
- mushrooms
- cauliflower
- snow peas
For those of you who are trying to lose weight, or are diabetic, you should know that sorbitol and xylitol are used as sweeteners in low-calorie sweets.
So what to do about the diet? It is recommended that you avoid all these foods for six to eight weeks, and then add back one food at a time to see if it causes you problems. Learn to read labels, because some of these complex sugars are contained in processed foods.
Small studies have shown that following this diet can significantly reduce symptoms in up to 75% of those who follow the diet.
Resources to read more: The FODMAP Diet
When Everyday Foods Are Hard to Digest
by admin | Nov 8, 2012 | Stress Management
Life Out of Control? Learn Stress Management & Anxiety Reduction
Managing stress is important in controlling headache frequency. But managing headaches is also essential. Headaches can exert a significant toll on everyday life.
Relationships can suffer—one study found that in 30% of cases, migraine sufferers reported tension with a spouse due to their migraine headaches, and 24% reported that sexual relations were impaired.
In a 1999 UK survey, 58% of migraine sufferers reported that migraines prevented them from maintaining a sexual relationship—this survey was of both sexes, not just women, it is important to stress. In a 1998 study, it was found that 10% of migraine sufferers who are parents reported losing patience with a child during a migraine attack, 22% felt that their children sought more attention because of their headaches, and 94% reported that their migraines interfered with parent/child activities.
So don’t let your headaches run your life—and don’t let your stress ramp your headaches up and out of control.
Do You Have Good Ways To Manage Stress?
We all have stress in our lives. It is not possible to do away with it. We can’t even really control it all. We can learn to manage stress, though. Here are some ways to cope:
- Learn better time-management skills.
- Become more organized.
- Learn to delegate.
- Practice yoga.
- Regular massages.
- Relaxation therapy.
- Biofeedback.
- Meditation.
- Have more fun.
Stress Management Techniques
The following are strategies that have been found in studies to work effectively for migraine management.
Biofeedback is a way of using your body’s own information – heart rate,blood pressure, skin temperature, or muscle tension to retrain your system and reduce headache frequency. It is noninvasive.
Relaxation training focuses on methods of instruction in relaxing specific muscle groups systematically. This helps you relax in general, as well as targeting muscles which may be tightening up and acting as headache triggers. The goal is to achieve a general feeling of calmness. It is considered both a physical and a psychological form of treatment.
Cognitive behavioral therapy is a form of psychotherapy that addresses unhelpful thoughts and beliefs, misperceptions, and faulty learning that can result in anxiety, depression, low self-esteem, and being “stuck” in one’s pain. It focuses on behavioral strategies to enhance coping skills, alleviate emotional distress, and promote positive change.
There is also a difference between regular everyday stress and the kind that is unusual and unhealthy. Sometimes this comes from problems you are having in your life, sometimes it comes from things in your past that are affecting your health now, and sometimes it just comes from coping with chronic headache pain.
There are specialized techniques for dealing with this kind of psychological stress in addition to the above:
- Cognitive therapy
- When appropriate, marital or family counseling
- Hypnotherapy
- Psychotherapy
by admin | Oct 1, 2012 | Women & Headaches
This article addresses questions most frequently asked by women with migraine who are planning a pregnancy. Please consult your own physician if you are pregnant or are planning a pregnancy.
I’m pregnant…but what’s going to happen to my migraine?
Results from studies suggest that at least 70% of women who have migraine without aura experience improvement in migraine during pregnancy, particularly during the second and third trimesters.1-4 Since migraine without aura is often associated with falling levels of oestrogen, the reason for improvement in pregnancy is often considered to be the more stable levels of oestrogen. However, there are many physical, biochemical, and emotional changes in pregnancy that could also account for improvement, including increased production of natural painkillers known as endorphins, muscle relaxation, and changes in sugar balance. In contrast to migraine without aura, attacks of migraine with aura follow a different pattern during pregnancy as attacks are more likely to continue and aura may develop for the first time.5-7
I’m pregnant…but is migraine going to harm my baby?
There is no evidence that migraine, either with or without aura, affects the risk of miscarriage, stillbirth or congenital abnormalities over and above the expected outcome for pregnancy in women without migraine.5,8
I’m pregnant…but what can I take to treat my migraine?
Drugs tend to exert their greatest effects on the developing baby during the first month of pregnancy, often before the woman knows she is pregnant. Hence take as few drugs as possible, in the lowest effective dose. Although many of the drugs taken by unsuspecting women rarely cause harm, there is a difference between reassuring the pregnant woman that what she has taken is unlikely to have affected the pregnancy and advising her what she should take for future attacks. Most evidence of safety is circumstantial; few drugs have been tested during pregnancy and breastfeeding because of the obvious ethical limitations of such trials. Hence drugs are only recommended if the potential benefits to the woman and baby outweigh the potential risks.
Non-drug treatment
Many pregnant women favour non-drug methods of management during pregnancy, particularly once they are aware that migraine is likely to improve with time. Early pregnancy symptoms such as sickness, particularly if severe, can reduce food and fluid intake resulting in low blood sugar and dehydration, aggravating migraine. Simple advice to eat small, frequent carbohydrate snacks and drink plenty of fluids may help both problems. Adequate rest is necessary to counter overtiredness, particularly in the first and last trimesters. Other safe preventative measures that can be tried include biofeedback, yoga, massage, and relaxation techniques. The benefits of these methods can last longer than the pregnancy!
Drugs to treat the symptoms of migraine
Pain killers
Most painkillers are safe to use in pregnancy. However, check with your doctor, particularly if you are getting headaches more often than a couple of days a week. Paracetamol (acetaminophen) is the drug of choice in pregnancy, having been used extensively without apparent harm to the developing baby.9 Aspirin has been taken by many pregnant women in the first and second terms of pregnancy.9, 10 However, it should be avoided near the expected time of delivery since it can increase bleeding. Codeine: Codeine is not generally recommended for the management of migraine in the UK.11 However, occasional use in doses found in combined analgesics is unlikely to cause harm. Ibuprofen: can be taken in doses not exceeding 600 mg daily.9
Antisickness drugs
Buclizine, chlorpromazine, domperidone (not available in the U.S), metoclopramide and prochlorperazine have all been used widely in pregnancy without apparent harm.
Triptans
Data from the large sumatriptan safety database, where inadvertent exposure to sumatriptan during pregnancy has occurred, are reassuring.12 However, continuing triptans during pregnancy is not recommended.
Ergots
Ergotamine should not be used during pregnancy as it can increase the risk of miscarriage and perinatal death.
Drugs to prevent migraine
If daily medication is considered necessary to prevent migraine during pregnancy, the lowest effective dose of propranolol is the drug of choice.9 Amitriptyline is a safe alternative.9 There are no reports of adverse outcomes from pizotifen (not available in the U.S.) used during pregnancy or lactation, although it is less often used than the drugs above. In contrast, sodium valproate, increasingly used for migraine prophylaxis, should not be taken during pregnancy in the absence of epilepsy as there is a high risk of fetal abnormalities.13 Indeed, women prescribed sodium valproate for migraine must use effective contraception. In general, other anti-epileptic agents prescribed for migraine prophylaxis cannot justifiably be recommended during pregnancy on the basis of currently available evidence.
I’m pregnant…but I got these funny blind spots with my migraine – should I see my doctor?
It is not uncommon for a woman to have her first attack of migraine aura during pregnancy. Symptoms are typically bright visual zig-zags growing in size from a small bright spot and moving across the field of vision over 20-30 minutes before disappearing. A sensation of ‘pins and needles’ moving up an arm into the mouth may accompany this. If you experience these typical symptoms and your doctor confirms that this is migraine, there is no need to be concerned and no tests are necessary. However, if the symptoms are not typical for migraine aura, it is important to exclude other disorders, such as blood clotting disorders or high blood pressure, which may occasionally produce symptoms not dissimilar from migraine.
What’s going to happen to my migraine after I have the baby?
If migraine has improved, this will usually continue until periods return. However, a bad attack of migraine can occur within a couple of days of delivery. This may be because of the sudden drop in oestrogen that occurs.14 Exhaustion, dehydration and low-blood sugar are other possible causes.
What can I take to treat my migraine if I’m breastfeeding?
The same drugs used in pregnancy can be taken while breastfeeding, with the following exceptions; aspirin is excreted in breast milk, so should be avoided during breastfeeding because of the theoretical risk of Reye’s syndrome and impaired blood clotting in susceptible infants; metoclopramide is not generally recommended during lactation since small amounts are excreted into breast milk. The triptans almotriptan, eletriptan, frovatriptan, rizatriptan and sumatriptan are licensed for use in breastfeeding provided that you do not breastfeed within 24 hours of the last dose. I would recommend similar advice for naratriptan and zolmitriptan.
Planning a pregnancy
If you are planning a pregnancy, now is the time to discuss with your doctor about any medication you are taking. If you are taking preventative treatments that are not recommended in pregnancy, consider stopping them and/or switching to a safer alternative. For drugs used to treat the symptoms of migraine, try to limit triptans to the first two weeks of the menstrual cycle, when you are unlikely to be pregnant. Now is also the time to get in shape for pregnancy, which will also help migraine – avoid skipping meals, take regular exercise, drink plenty of fluids and start taking a multivitamin supplement for use in pregnancy.
Migraine and Pregnancy Summary Points
- Migraine may worsen in the first few weeks of pregnancy but usually improves by 16 weeks of pregnancy.
- Migraine does not harm the baby.
- Paracetamol/acetaminophen is safe throughout pregnancy and lactation. Aspirin is also safe, but may cause bleeding problems if taken near term.
- Prochlorperazine has been used for pregnancy-related nausea for many years.
- Metoclopramide and domperidone are safe, but are probably best avoided during the first trimester.
- For continuing frequent attacks, which warrant daily preventative treatment, propranolol has best evidence of safety during pregnancy and lactation.
- If you have taken triptans and then find you are pregnant, do not worry. However, continued use during pregnancy is not recommended.
Rapid advances in medicine may cause information contained here to become outdated, invalid or subject to debate.
References
1. Maggioni F, Alessi C, Maggino T, Zanchin G. Headache during pregnancy. Cephalalgia1997;17(7):765-9.
2. Sances G, Granella F, Nappi R, et al. Course of migraine during pregnancy and postpartum: a prospective study.Cephalalgia 2003;23(3):197-205.
3. Chen T-C, Leviton A. Headache recurrence in pregnant women with migraine. Headache 1994;34:107-110.
4. Granella F, Sances G, Pucci E, Nappi R, Ghiotto N, Nappi G. Migraine with aura and reproductive life events: a case control study. Cephalalgia2000;20:701-7.
5. Wright G, Patel M. Focal migraine and pregnancy. BMJ 1986;293:1557-8.
6. Chancellor A, Wroe S, Cull R. Migraine occurring for the first time in pregnancy. Headache1990;30:224-7.
7. Cupini L, Matteis M, Troisi E, Calabresi P, Bernardi G, Silvestrini M. Sex-hormone-related events in migrainous females. A clinical comparative study between migraine with aura and migraine without aura. Cephalalgia 1995;15:140-4.
8. Wainscott G, Sullivan M, Volans G, Wilkinson M. The outcome of pregnancy in women suffering from migraine. Postgrad Med1978;54:98-102.
9. Rubin P, ed. Prescribing in Pregnancy. 3rd ed. London: BMJ Books, 2000.
10.Slone D, Siskind V, Heinonen O. Aspirin and congenital malformation. Lancet 1976;i:1373-5.
11.Steiner T, MacGregor E, Davies P. British Association for the Study of Headache. Guidelines for all doctors in the diagnosis and management of migraine and tension-type headache. Management Guidelines 2004 available at www.bash.org.uk
12.Loder E. Safety of sumatriptan in pregnancy: a review of the data so far. CNS Drugs 2003;17(1):1-7.
13.Lindout D, Schmidt D. In utero exposure to valproate and neural tube defects. Lancet 1986;ii:1142.
14.Stein G. Headaches in the first post partum week and their relationship to migraine. Headache1981;21:201-5.
written by E. Anne MacGregor, MD
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