Headaches in Women: Better Diagnosis and Management ------------------------------------------------------------------------ In conjunction with this year's AAPA meeting in Atlanta, a leading specialist in neurology presented an overview of the pathology, differential diagnosis, and management of headaches - including migraines - in women. ------------------------------------------------------------------------
Headaches in Women: Better Diagnosis and Management
"A majority of individuals who experience recurrent, chronic headaches suffer from either tension-type or migraine headaches," said Mark W. Green, MD, Clinical Professor of Neurology at New York Medical College in Valhalla and Associate Director of the Headache Institute, Beth Israel and St. Luke's-Roosevelt Hospital Centers, in New York, New York. Dr. ! Green explained that, while many types of headaches are possible, 90% are tension-type or migraine. Despite its prevalence and severity, migraine continues to be an underdiagnosed and undertreated disorder. Diagnostic Workup Complaint of a recurring, chronic headache requires thorough evaluation to rule out brain tumor or other serious disease. A complete workup is warranted if initial onset of the headache occurs after age 40, headache symptoms increase in frequency or severity, or focal signs are reported or present on physical examination. The workup consists of a detailed patient history, complete physical examination, neuroimaging (MRI is preferred in most cases), and laboratory testing as appropriate. These diagnostic steps enable the clinician to successfully distinguish between migraine and other types of headache such as brain tumor, subarachnoid hemorrhage, idiopathic intracranial hypertension, and infection such as meningitis or Lyme disease. Migra! ine and tension-type headaches can be particularly difficult to disti nguish from each other, said Dr. Green. "Many patients say their headache begins as a tension-type and turns into a migraine - or vice versa," said Dr. Green. It is likely that tension and migraine headaches are opposite ends of a continuum of the same headache type, and often both headaches respond to the same medications. However, Dr. Green cautioned clinicians not to make the response to a medication a diagnostic test. "A patient with subarachnoid hemorrhage or meningitis may respond well to a migraine medication, but this will not address the more serious problem," he said. Pathology of Migraine Headache According to Dr. Green, 18% of women suffer at least one migraine per year, with initial onset usually occurring in childhood or adolescence, peak incidence around age 40. Migraine headache is disabling because of pain as well as other symptoms (Table 1). Table 1. Symptoms of Migraine Headache Symptom Prevalence (%) Nausea 87 Vomiting 16 Diarrhea 16 Photophobia 82 Visual disturbances 36 -fortification spectra 10 -phototopsia 26
Paresthesias &! nbsp; 33 Scalp tenderness 65 Lightheadedness 72 Vertigo 33
Alteration of consciousness 18 -seizure 4 - syncope 10 - confusional state 4
There are many triggers of migraine in women, including certain foods, stress, exertion, and fluctuations in estrogen levels. Typically, a migraine begins with prodrome, and may or may not have an a! ura. Prodrome may consist of certain food cravings (chocolate), heightened sensitivities, and/or mental changes such as depression or euphoria. The headache itself is usually (but not necessarily) unilateral, pulsatile, and may involve various autonomic symptoms such as light and sound sensitivity. The attack is exacerbated by routine exertion and generally lasts from 4 to 72 hours. A number of different types of migraines in women are documented, the most common of which is menstrual migraine. Approximately 60% of women migraineurs report headaches associated with menses, although less than 15% experience migraine headache exclusively of this type. The menstrual migraine is triggered by a decrease in estrogen and is most common at onset of flow. It is often a long-lasting headache and the most difficult to treat. Abortive Treatments for Migraine Headache There are several options for treatment of migraine headache. Clinicians should be aware of the advantag! es and disadvantages of the various agents available. Opiates. Many emergency room (ER) clinicians report that narcotics are the drugs of choice for migraine. "Actually, opiates make patients more nauseated, they cause vasodilation, and they do not sufficiently relieve migraine pain," said Dr. Green. Antiemetics. A better treatment choice in the ER are antiemetics. Intravenous drugs, such as chlorpromazine (Thorazine) and prochlorperazine (Compazine), are very helpful in managing a migraine attack. However, an antiemetic is often not the best choice because the patient may be tired and unable to return to work. Nonsteroidals. Nonsteroidal anti-inflammatory drugs (NSAIDs) offer effective treatment for mild migraine attacks. These agents generally do not cause rebounding, fatigue, or nausea. However, NSAIDs are not effective against more severe migraines. Ergots. Ergots are less frequently used for treatment of migraine, according to Dr. Green. However, dihydroergotamine mesylate (DHE 45, Migranal), available for paren! teral or nasal administration, has a long half-life and a low rate of headache recurrence. "Overall, the ergots can cause nausea and are not as effective as the triptans," said Dr. Green. Triptans. According to Dr. Green, "The triptans have revolutionized migraine therapy. These drugs effectively reduce nausea, vomiting, photophobia, phonophobia, and allow the patient to remain alert." Moreover, the most difficult migraine to treat, menstrual migraine, responds well to triptan therapy. The first triptan approved, sumatriptan (Imitrex) is available for oral, nasal, and injected administration. "Injectable sumatriptan is the most effective drug for migraine that we have encountered so far, with close to 90% efficacy in a matter of hours," he noted. The nasal and oral drug forms are similar to each other in efficacy, but the nasal spray produces quicker relief. Additionally, nasal spray, rather than a tablet, is a better choice for ! a nauseated patient. Other oral triptans - rizatriptan (Maxalt) and z olmitriptan (Zomig) - are also effective rescue drugs. "The fundamental advantage to using oral sumatriptan over another oral triptan is the ability to mix and match dosage forms," he explained. "All triptans are good choices, but if we start with oral rizatriptan or zolmitriptan and it is not effective, we cannot then give the sumatriptan injection." Another triptan, naratriptan (Amerge) has a longer half-life, low recurrence rate, and good side effect profile. "This drug takes a little longer to work than other triptans, but is a good option for patients who experience long-lasting migraine attacks or troublesome side effects with other anti-migraine drugs." Dr. Green noted that if one triptan does not work for a patient after two or three migraine episodes, another triptan may be more effective and should be tried. Prophylactic Treatment of Migraine Headache Unfortunately, prophylactic treatments for migraine are not as effective! as abortive therapies, said Dr. Green. "Overall, 50% of patients on prophylactic therapy will have a 50% reduction in headaches" he said, pointing out that prophylactic treatment should be considered primarily in patients who have frequent migraine attacks. Clinicians and patients should not expect prevention of all migraine attacks. While certain beta-blockers, calcium channel blockers, and tricyclic antidepressants can be used to prevent migraines, the most promising agents may be the anticonvulsants. Divalproex sodium (Depakote), approved by the Food and Drug Admin-istration for prophylactic treatment of migraine, is particularly effective. In addition, prevention of menstrual migraines may be achieved by using NSAIDs or ergots just before onset of menstruation. However, Dr. Green pointed out that if an ergot is taken as prophylaxis and is ineffective, a triptan may not be used as abortive therapy. Conclusion In closing, Dr. Green noted that, w! hen choosing an abortive therapy for migraine, it is important to con sider the speed of onset of the attack, the extent of nausea and vomiting, and the length or recurrences of an attack. Finally, if headache symptoms change in nature or increase in frequency or severity, re-evaluation is warranted.
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