Use new screening tool for menstrual migraine
The woman in your exam room says she has severe headaches that usually begin about two days before her menstrual cycle. When they occur, they get more severe in intensity. She does not report any signs of neurological aura, such as flashing lights or tingling sensations, with the headaches. What's your diagnosis?
All signs point to menstrual migraine. To help women's health care providers identify menstrual migraine and track their prevalence, researchers have developed a three-question questionnaire. According to results presented at the May 2008 American College of Obstetricians and Gynecologists (OB/GYN) annual meeting, the questionnaire has a sensitivity of 94% and a specificity of 74%.1
It is important that providers accurately access the presence of menstrual migraine. More than 50% of women with migraine report an association between migraine and menstruation; 12 million women experience worsening of migraines in association with the menstrual cycle.2,3 Further research indicates an association with menses is observed by 60% of women with migraine headaches. In 7%-14% of women with migraines, headaches occur exclusively with menses.4 Headache pain associated with menstrual migraine has been shown to be more severe, less likely to respond to treatment, and more likely to be associated with nausea and vomiting than that associated with nonmenstrual migraine headaches.5
"We think these are very simple questions that could be put in a waiting room in an OB/GYN office in order to identify patients who are likely to have migraine and who therefore are likely to have impact in their lives from migraine," says Stewart Tepper, MD, director of research for the Center for Headache and Pain at the Neurological Institute of the Cleveland Clinic Foundation. "The purpose of the questionnaire is to simplify things for the gynecologist and to increase the likelihood that a significant disabling illness could be addressed by the gynecologist, because they serve as primary care physicians."
Ask the questions
To develop the questionnaire, Tepper and research colleagues administered a nine-item questionnaire to patients from a headache clinic with unknown menstrual migraine status. The attributes of each question were compared to a validated headache calendar to develop a three-item menstrual migraine questionnaire. The headache calendar and questionnaire then were administered to nonpregnant/nonmenopausal OB/GYN patients. A diagnosis was assigned by a blinded specialist using the headache calendar.1
The three items on the menstrual migraine questionnaire include:
- Do you have headaches that are related to your period most months?
- When your headaches are related to your period, do they eventually become severe?
- When your headaches are related to your period, does light bother you more than when you don't have a headache?
Researchers found that if women responded positively to the first question and to one or both of the other two questions, the screening tool had a sensitivity of 0.94 and a specificity of 0.74 for detecting pure menstrual migraines.1
Check treatment options
While most women's health providers assume that most of their patients have headaches, providers need to dig deeper to find out whether a woman's menstruation is associated with the headache, says Lee Shulman, MD, professor in obstetrics and gynecology and chief of the Division of Reproductive Genetics in the Department of Obstetrics and Gynecology at the Feinberg School of Medicine of Northwestern University in Chicago. If headaches are delineated, even if they are menstrual-related, consideration of referral to a headache center or headache expert is warranted to ensure that there is not a serious cause for the headache, Shulman contends.
Triptans, which include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan, are effective in the acute treatment of menstrual migraine.6 Triptans generally are well tolerated, and the long-term safety of these drugs is being evaluated.7
The consistent ebb and flow of hormones during the reproductive cycle functions as a trigger in preventing or provoking migraine. Providers may look at using perimenstrual estrogen supplements to blunt the drop in estrogen or prescribe a continuous regimen of combined oral contraceptives to avoid hormonal fluctuations. There are risk factors associated with estrogen use; the use of oral contraceptives in women with migraine is an independent risk factor for stroke.8
"What we don't really have are good randomized controlled trials that either strategy is particularly effective," says Tepper. "There may be a misperception that we actually have evidence-based results."
References
- Sheftell FD, Zatochill MK, Szeto M, et al. Development of a simple menstrual migraine screening tool for obstetric and gynecology clinics. Presented at the 56th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists. New Orleans; May 2008.
- MacGregor EA. Menstrual migraine: A clinical review. J Fam Plann Reprod Health Care 2007; 33:36-47.
- Lay CL, Mascellino AM. Menstrual migraine: Diagnosis and treatment. Curr Pain Headache Rep 2001; 5:195-199.
- Speroff L, Fritz MA. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia: Lippincott, Williams & Wilkins; 2005.
- MacGregor EA, Hackshaw A. Prevalence of migraine on each day of the natural menstrual cycle. Neurology 2004; 63:351-353.
- Peterlin BL. Menstrual migraine: Therapeutic and management strategies. OBG Management 2008. Accessed at www.obgmanagement.com.
- Tepper SJ. Tailoring management strategies for the patient with menstrual migraine: Focus on prevention and treatment. Headache 2006; 46(suppl 2):S61-68.
- Loder EW, Buse DC, Golub JR. Headache as a side effect of combination estrogen-progestin oral contraceptives: A systematic review. Am J Obstet Gynecol 2005; 193:636-649.
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