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Medications May Split Up Pain Associated with Migraines

By Mark A. DeMasi

Approximately 28 million Americans suffer from migraines. Treating them continues to be a challenge for the people who suffer from this disabling condition and for the healthcare providers who treat these patients. The annual cost for the treatment of this condition in the United States is estimated to be at least $17 billion dollars.

Women are two times more likely to suffer from migraine headaches than men. Of these women, 60 to 70 percent have headaches with a menstrual relationship. While this association is widely recognized it is not completely understood how hormonally associated migraines differ from non-hormonally related migraines.

Types of migraines

There are two separate and distinct migraine entities associated with a woman’s menstrual cycle. The first condition is known as menstrually associated migraine or MAM. This condition behaves more like a muscle tension headache and is easier to treat. The pain is usually mild to moderate in intensity. This condition is usually seen just prior to ovulation and during a women’s menses. The second type of migraine associated with a woman’s menstrual cycle is called a menstrual migraine. The pain associated with this condition is often characterized as being “crushing and brutal” in nature. True menstrual migraine starts almost exclusively two days prior to the onset menses and can last up to the first three days of menses. This five-day window, known as a menstrual window, is extremely resistant to any form of treatment. The trigger, or causative agents, for these types of migraines are caused by decreasing estrogen levels in a woman’s body.

Diagnosis

The diagnosis of either of these conditions is made through a thorough history of the patient’s migraine history, along with a complete physical exam. Critical to any evaluation and treatment plan for a patient is the use of a headache diary. This invaluable tool allows for tracking of the patient’s headache pattern, duration of the headache and severity of the migraine pain. The diagnosis of hormonally associated migraine can be made simply by the patient’s history, physical exam, and headache diary.

Special imaging studies, such as CAT scans and MRI studies are only warranted when:

• A patient complains that the headache pain is the worst pain ever experienced – often called the “Thunderclap Migraine.”
• The migraine pain is progressively becoming worse.
• Pain that is one sided and unrelenting.
• Pain that is unresponsive to normal migraine therapy.
• Migraine is associated with an abnormal neurologic finding such as slurring of one’s speech or any loss of muscle strength.

Treatment

Successful treatment of women with either of these conditions is based upon the proper diagnosis and initiation of the appropriate medical therapy. The goal, if possible, is prevention. Successful treatment must be individualized. Aggressive management by a healthcare provider is essential to improve the quality of life for the individuals who suffer from these types of migraine.

Medical Therapy used to treat a migraine:

• Menstrually Associated Migraine (MAM) as stated previously, this type of migraine pain is not as debilitating as a true menstrual migraine. In most cases, treatment for this condition would involve the use of birth control pills. This would give women an even level of circulating estrogen. Also, the use of non-steroidal anti-inflammatory agents such as Motrin, Aleve or Advil would be appropriate. Rarely are narcotics needed to treat this type of headache.
• True Menstrual Migraine is an incapacitating medical problem. Once the migraine has started, it is almost impossible to break. The development of a family of medications, known as the “Triptans” have been successful in treating, and in some cases preventing this type of migraine. Long acting Triptans, Frovatriptan (i.e. Frova) and Naratriptan (i.e. Amerge) have been extremely successful in the treatment of this condition. Narcotics do play a minor role in the treatment of these patients. Long acting narcotics are best used in those patients as second line therapy. The long acting narcotics may be used when a migraine has become full-blown and are used while the Triptan has had time to take effect.

No single medication is completely side effect free. However, the development of triptans has given hope to 28 million Americans, especially 14 million women.

Mark A. DeMasi, D.O. is board certified in Obstetrics and Gynecology and a Distinguished Fellow in the American College of Osteopathic Obstetricians and Gynecologists.