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Menopause Matters

Headaches in the Perimenopause
Managing Techniques

Margaret F. Moloney, RN-C, PhD, ANP

Headaches are a relatively minor problem for most women; however, some experience headaches that are so severe they greatly interfere with their quality of life. For perimenopausal women, evidence suggests that the ovarian hormonal fluctuations that occur during this transition time can worsen existing headaches or cause new ones.

HEADACHE TRIGGERS
In addition to hormonal fluctuations, a variety of factors (ie, "triggers") are thought to produce migraines in perimenopausal women. The most common nonhormonal triggers identified include the following:

• Consumption of alcoholic beverages, caffeine, tyramine-containing foods (eg, chocolate, yogurt, sour cream, aged cheese, red wine), foods containing nitrite preservatives (eg, hot dogs, sausage, bacon, bologna, smoked fish), and foods containing monosodium glutamate (a flavor-enhancer sometimes added to Chinese food as well as processed or frozen foods).
• Change in eating pattern, such as fasting or skipping meals, not drinking enough water.
• Change in sleeping pattern, such as getting too much or too little sleep.
• Emotional changes, such as stress, anxiety, anger, or excitement.
• Environmental factors, such as noise, bright lights, changing barometric pressure, or inhaling fumes.

Some research studies suggest that fluctuations in estrogen levels during perimenopause are associated with increases in the prevalence and/or intensity of headaches. Also, women with a history of menstrual headaches may find that their headaches become worse during perimenopause.^1,2 About two thirds of women with migraines experience a remission of their headaches after menopause.^2,3

Keeping a "headache diary" for a few weeks may help pinpoint the trigger(s). Women should record the times a headache was experienced, describe the symptoms, and identify potential precipitating factors (eg, particular foods, noise, or stress). Identifying patterns can help to determine how to prevent headaches. Attention to the relationship between women's menses or other hormonally related symptoms can be key in identifying if hormonal fluctuation has a role in causing headaches.

MANAGEMENT OF HEADACHES
The most common type of headache is the tension headache, described as a steady squeezing or pressing pain on both sides of the head. These headaches can be acute or chronic, lasting from 30 minutes to 1 week, and they are not aggravated by exertion. Most can be effectively treated with nonprescription analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, aspirin, acetaminophen, ibuprofen). Nonpharmacologic therapies, including physical therapy, stress management, relaxation therapy, and biofeedback, are also helpful for some people. For women who need prophylactic treatment, tricyclic antidepressants or selective serotonin-reuptake inhibitors are an option. Muscle relaxants have not been found to be effective for tension-type headaches.

Migraine headaches produce more severe pain and can usually be more difficult to treat than other types of headaches. Migraines are described as a moderate to severe throbbing pain that is worse on one side of the head. The pain is usually aggravated by physical activity. Symptoms such as nausea, vomiting, and light sensitivity are often present. Migraines last 4 to 72 hours and may occur rarely or up to several times a week. In the United States, migraines affect about 18% of women.⁴

For some women with mild to moderate migraines, over-the-counter preparations, such as aspirin, acetaminophen, and caffeine combinations, can be as helpful as prescription medications. For more severe migraines, the triptan medications, such as sumatriptan (Imitrex), zolmitriptan (Zomig), and rizatriptan (Maxalt), are extremely effective. NSAIDs, such as naproxen, are also effective for some migraine sufferers, particularly when used with a triptan. The combination drug of isometheptene mucate, dichloralphenazone, and acetaminophen (Midrin), which is used primarily to treat acute migraines, has been found to be effective in treating mixed tension-type/migraine headaches.⁵ However, it should be used with caution, as it may be habit-forming.

Both OTC and prescription drugs used for acute treatment can result in rebound headaches. Care should be taken to monitor their use, and if headaches occur more than twice a week, preventive medications should be considered. Preventive medications are about 60% effective, although the effectiveness can vary from person to person. Drugs found to be most useful in preventing migraines include beta blockers, such as propanolol (Inderal); tricyclic antidepressants, such as amitriptyline (Elavil); and anticonvulsants, such as divalproex sodium (Depakote).⁵ With a preventive drug, starting doses should be low. Doses should be increased slowly, and drugs should be taken for at least 2 months to judge success.

The role of hormone therapy in headache management is unclear. For some women, especially those with apparent hormone-related headaches, taking estrogen replacement therapy (ERT) or estrogen plus progestogen, either as oral contraceptives (OCs) or as hormone replacement therapy (HRT) may help. A low-dose estrogen patch applied during the at-risk time in a woman's natural cycle may help modulate hormone changes and prevent menstrual headaches. A continuous HRT regimen is preferred for postmenopausal women, and experimenting with different doses, regimens, and estrogens may be required.

It is also important to question women who have headaches while taking OCs about the timing of their symptoms, as they may be caused by estrogen withdrawal during the placebo week. These women can take a low-dose estrogen supplement during the placebo week.

In some women, ERT/HRT and OCs can exacerbate migraines, and should be discontinued if this occurs. Using estradiol instead of other estrogens may improve headaches.⁶ Caution should be used when prescribing OCs or ERT/HRT for a woman who has migraine with aura, usually visual symptoms, lasting from 5 to 30 minutes before the onset of a migraine. Studies suggest that women with aura have an increased risk of stroke, and hormone therapy may add to the risk.^7-9

Some evidence suggests that progestogens can precipitate or aggravate headaches.¹ With HRT, if headaches are worsened by medroxyprogesterone acetate, a change to micronized progesterone could help. As mentioned, continuous HRT regimens may provide greater hormonal stability than cyclic HRT, which can reduce the incidence of headaches by smoothing out the hormonal fluctuations. Like other medications taken to alleviate or prevent headaches, HRT may require a trial of weeks to months before improvement is seen.

For many clinicians treating perimenopausal women who suffer from headaches, finding an effective management program for headaches may require testing various interventions and regimens, pharmacologic and nonpharmacologic. Establishing a supportive relationship with the woman can be an extremely effective adjunct in facilitating the search for an appropriate, individualized headache management program.

Margaret F. Moloney, RN-C, PhD, ANP, is associate professor of nursing (clinical), Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA. Dr. Moloney is a member of The North American Menopause Society.

REFERENCES

1. MacGregor EA. Menstruation, sex hormones, and migraine. Neurol Clin. 1997; 15(1):125-41.
2. Fettes I. Migraine in the menopause. Neurology. 1999;53(4 suppl 1): S29-S33.
3. Neri I, Granella F, Nappi R, et al. Characteristics of headache at menopause: a clinico-epidemiologic study. Maturitas. 1993;17(1):31-37.
4. Lipton RB, Stewart WF, Diamond S, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41(7):646-657.
5. Walling AD. Drug prophylaxis for migraine headaches [erratum in Am Fam Phys 1990;42:1220]. Am Fam Physician. 1990;42:425-432.
6. Rasmussen BK, Olesen J. Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia. 1992 Aug;12(4):221-228; discussion 186.
7. Giammarco R, Edmeads J, Dodick D. Critical Decisions in Headache Management. London, GB: BC Decker, Inc; 1998.
8. Becker WJ. Use of oral contraceptives in patients with migraine. Neurology. 1999;53(4 Suppl 1):S19-S25.
9. Bousser MG. Stroke in women: the 1997 Paul Dudley White International Lecture. Circulation. 1999 Feb 2;99(4):463-467.

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