Monday, November 17, 2014

Fertility, Hormones, Headaches, Oh My

A little endometriosis and fertility advice below, but otherwise, this is a perimenopause & migraine post.

Did you know there are entire blogs devoted to perimenopause and menopause? That's how big an issue it is in a woman's life. Mine is a small blog with mostly anonymous readers; I can't even guess how many of you are in your forties, but if you are one of those lovely ladies, read on.

My research taught me that a woman will start skipping periods after a big hormone surge--kind of a last hurrah. Last month was my worst headache experience yet, so I thought "The last hurrah. It's here!"

But alas, on day 13 my ovaries performed as usual--something which used to be a blessing to me (feeling that familiar pain in my side). This time I only dreaded the headaches to follow. (At this phase, I do not ovulate every month now, but the cycles come at regular intervals, still.)

Researchers have recently pinpointed the one symptom that signals the start of perimenopause--perimenopause being a phase that, on average, lasts four years. That symptom is a change in flow--usually heavier. Some women begin this phase in their late thirties, and some women not until their late forties or early fifties.

I had endometriosis in my teens and twenties, characterized by heavy, painful periods, but a couple years after I married and started my family, I was either pregnant or nursing and experienced few to no periods for 10 full years, during which my endometriosis disappeared.

If you have endometriosis I recommend you nurse as long as possible and try to conceive your next baby as soon as signs of ovulation return, so as not to allow the disease to make a comeback. Monthly periods allow endometriosis to continue to grow. Continue this sequence--pregnancy, long-term nursing, pregnancy--until you've completed your family.

I actually think a women is very fertile in the window right after her ovulation resumes during nursing, which can be anywhere from 6 months to 18 months, or sooner for some women. You can nurse while you are pregnant for as long as your baby is interested, as long as you monitor your diet for adequate nutrition.

In my forties--around forty-five I think--I thought endometriosis had returned, but in fact, those symptoms were the start of perimenopause. Around that same time, I began to get powerful mood swings and surprisingly strong anger flashes, but those are gone now.

The next phase was these migraine headaches that go for days and days. Now I can't wait for the whole thing to be over, although when hot flashes come I might feel differently. I imagine those will add some laundry and much aggravation. I get hot and cold sometimes during the winter, but it seems to be more related to patterns of inactivity while schooling the kids, mixed with frenzied chore time.

I nursed my last child until I was 47, so my experience with estrogen levels in the forties was probably unusual. My youngest daughter has an autoimmune disease, so she needed the antibodies from breastmilk longer than most children do.

On Migraines and Hormones

I've perused many articles to find headache answers, but most focus on hormone replacement therapy, which is dangerous, in my view. My mother had a small cancerous breast lump removed in her sixties, partially because she was on hormone replacement therapy for over 10 years. She also has been a heavy drinker and smoker for years, and has been sedentary but not overweight. The hormone therapy is known to cause breast cancer. My mother has had no recurrence since, thank God. She has five sisters all older than her, none of whom have any breast cancer. Her mother was also clear, and lived free of any cancer up until her death at 88.

Headache/Hormone Connection: Female migraine sufferers typically get more headaches before and after periods begin. That is when hormone levels are falling. Again in perimenopause, estrogen levels are falling, so headaches are present more days per month.

My research has led me to a few remedies, some of which might bring hope to you:

~ Focus on other migraine triggers, since you can't do much about the hormone trigger: adequate sleep, same wake and bedtimes, keep blood sugar levels steady, avoid hunger, avoid stress (ha ha), exercise regularly, stay hydrated, don't smoke, cut back on caffeine and alcohol

~ Dietary supplements: feverfew (not during pregnancy or nursing), butterbur, B-2 (riboflavin), co-enzyme Q-10, and magnesium

~ Try naproxen (Aleve) during the days you get the worst hormone headaches. This has been proven to cut back on the headaches because it inhibits the release of hormone (same reason NSAID's like ibuprofen work best for menstrual cramps). It is typically prescribed for 2 days before the flow and for 3 days into the flow, Of course NSAID's come with side effects, but doctors say for this small window we aren't to worry. My window of headache days would be higher than the five mentioned above, but I plan to try this for this month and see what happens.

Here is an excellent summary from the American Headache Society on treating Menstrual Migraine:

If you've had no success with your headaches, I recommend you take this article to your doctor for discussion. In reading it, I discovered that my doctor didn't prescribe Topomax for me correctly. In both the first and second attempts, the dose was too low. Here is the full article, most of which I've pasted below--but do go to the link for the rest of it, so you can read about preventative methods and print it out for your doctor. And if your headache status changes because of anything on this article, could you share that with me, please? It might just help me and others. Thank you!

Menstrual migraine is divided into 2 types:

1. Pure Menstrual Migraine: migraine without aura that occurs exclusively
during the 5-day perimenstrual window of -2 through +3. This affects
approximately 14% of female migraineurs.

2. Menstrually Related Migraine: migraine without aura that occurs during
the 5-day perimenstrual window of -2 through +3 but occurs at other times
of the cycle as well. This is present in approximately 50% of female
migraine patients.


Treatment for acute menstrual migraine is similar to non-menstrual migraine acute treatment. However, many women report that their menstrual migraines are more difficult to treat. The clinical desired end-point of headache-free in 2 hours is a reasonable treatment goal for evaluating the effectiveness of acute therapy. The following is a list of commonly used treatment options: 

1. Acetaminophen-Aspirin combinations with and without caffeine (e.g. brand name Excedrin; the caffeine can potentiate the analgesic effect)
2. Naproxen (Aleve) 250 mg 1-2 every 8-12 hours prn
3. Ibuprofen (Advil/Motrin) 800 mg every 8-12 hours prn
4. Naproxen (Naprosyn) Rx strength 500 mg every 12 hours prn
5. Ketorolac (Toradol) 30-60 mg IM prn to rescue (NSAID)
6. Triptans-oral; nasal spray; injectable.
a. Almotriptan (Axert) 12.5 mg every 2 hours; max 25 mg in 24 hrs
b. Naratriptan (Amerge)2.5 mg every 4 hours; max 5 mg in 24 hours
c. Frovatriptan (Frova ) 2.5 mg every 2 hours; max 7.5 mg in 24 hours
d. Sumatriptan (Imitrex) 50-100 mg every 2 hours; max 200 mg in 24 hours
e. Rizatriptan (Maxalt) 10 mg every 2 hours; max 30 mg in 24 hours
f. Eletriptan (Relpax )40 mg every 2 hours; max 80 mg in 24 hours
g. Zolmitriptan (Zomig)) 2.5-5 mg every 2 hours; max 10 mg in 24 hours
h. Sumatriptan (Imitrex) 20 mg nasal spray 1 spray 1 nostril; may repeat in 2 hours to max of 40 mg in 24 hours
i. Zolmitriptan (Zomig) 5 mg nasal spray 1 spray 1 nostril; may repeat in 2 hours to max of 10 mg in 24 hours
j. Sumatriptan (Imitrex) 4-6 mg injectable; may repeat in 1 hour to max of 12 mg in 24 hours
7. Triptan/NSAID combination such as Sumatriptan (Imitrex) 100 mg & Naproxen 500 mg (Naprosyn)
8. DHE/dihydroergotamine (Migranal)1 spray each nostril; repeat in 15 minutes
9. Butalbital-containing products with or without codeine such as Fiorinal plain or Fiorinal with codeine; not a good choice unless patient can’t tolerate the triptans and the ergots/ergot alkaloids which are more migraine specific
10. Narcotic such as Hydrocodone (Vicodin) sparingly to rescue only: 1-2 of the 5 mg every 6 hours prn severe migraine only (suggest limit max 15/month)

1. Mild-moderate menstrual migraine: OTC NSAID/combination product; Rx NSAID, e.g. Naproxen 500 mg prn
2. Moderate-severe: triptan +/- NSAID
3. Rescue: Sumatriptan 4-6 mg sq; Ketorolac 30-60 mg IM; DHE .5 mg NS each nostril; repeat in 15 minutes; DHE-45 .5-1 mg IM or IV every 8 hours


This treatment approach is ideal for many women who suffer from menstrual migraine. The majority of women report they have migraines outside of the menstrual window; however, their non-menstrual migraines are often easier to treat. Many may report that their normal acute treatment for migraine does not work for menstrual migraine. Additionally, many are afraid they will take the full allotted amount of triptan medication for their menstrual migraine which can last 3-7 days. An effective short-term preventive approach should lessen both the severity and duration of the menstrual migraine. Common short-term preventive strategies:

1. Magnesium 360-400 mg during the luteal phase of the cycle; i.e. begin around day 14 of the cycle. Limiting potential side-effect: diarrhea.
2. Naproxen 500 mg twice a day; begin several days before the anticipated onset of menstrual migraine; continue until at least day 3 of cycle. Advantage: low cost. Potential side-effect: nausea/GI.
3. Triptan (one of the 7) dosed in a bid fashion. Begin several days before anticipated onset of menstrual migraine. Use the highest dose of the triptan. May combine with a NSAID such as naproxen 500 mg. Use for 5 days in most cases. Be aware, this extended duration use of triptans is not FDA-approved and information on long-term safety is not available for triptans when dosed in this mini-prophylaxis manner. 
4. Increase does of daily preventive that the woman is already on; e.g. if on topiramate (Topomax) 50 mg hs to prevent headache, increase to 75-100 mg during her vulnerable menstrual migraine time of cycle. Advantage: the patient does not feel they are taking an unnecessary dose of their preventive during their non-menstrual time of month.
5. Estradiol patch .1 mg (name brand Climara .1 mg; Vivelle dot .1 mg) to wear for at least 1 week to prevent the drop in estradiol that is often a catalyst for the menstrual migraine; the women should apply the patch on approximately day -3 and stop when menses complete. This can be done
in conjunction with an oral contraceptive if the contraceptive is taken cyclically. The transdermal estradiol patch can also be used in women who don’t take contraception as it will help prevent the natural endogenous drop in estradiol.
6. Oral estradiol tablets the week of menses. However, they don’t give as even a level of estradiol as the transdermal patch and are only recommended if women can’t tolerate the transdermal estradiol patch. Dose: Estradiol 1 mg dose dosed qd or bid.

1. Magnesium 360-400 mg qd; Naproxen 500 mg bid; begin day 14 of cycle; continue through completion of menses
2. Triptan for 5-6 days; e.g. Frovatriptan (Frova) 5 mg loading dose followed by 2.5 mg bid for 5 days; begin -2 of cycle
3. Alternative triptan: Naratriptan (Amerge) 2.5 mg bid or ½ tablet bid for 5 days

PREVENTIVE TREATMENT --see link for the rest of this portion

This approach is ideal for women who suffer from a lot of non-menstrual migraine as well asmenstrual migraine or for women who are suffering despite optimal acute and short-term treatment. Preventive treatment can be broken into 2 categories: traditional daily preventive medication and hormonal manipulation.

Most common preventive treatment (traditional): 
1. AED’s (Anti-epileptic) medication such as topiramate (Topomax) and divalproex sodium (Depakote). For Topamax, start with 25 mg qd; increase by 25 mg/week until 100 mg or until clinical desired end-point. If necessary increase up to 200 mg daily dose. Dose bid or all at bedtime if sedation noticed. Most common side-effects: paresthesias (usually mild and transient); sedation; word-retrieval problems; appetite suppression and weight-loss.

No comments: