Migraine is a gender pathology: out of 4 people who suffer from it, 3 are women. And they, women, experience more frequent, more painful, longer-lasting migraine episodes that follow the trend of hormones that changes over time and with age: from childhood to menopause. Fondazione Onda and Anircef, the Italian neurological association for research on headaches (migraines are headaches that affect half the skull) have set up an interdisciplinary group of experts that includes neurologists, gynecologists and pediatric oncologists with the aim of developing a new model of ad hoc management for women with migraine: the Migraine Woman path.
The first results of the panel of specialists were presented in Rome on 31 January “and undoubtedly represent the beginning of a great work to be carried forward – he said Francesca Merzagorapresident of the Onda Foundation – We hope that the experience of this working group can lead to the development of a bio-psycho-social model for the management of women with migraines, which takes into account all the specificities of the female life stages, starting from pre-adolescence to menopause”.
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From childhood to menopause
Although the female component is decidedly more represented within the migraine sufferer population (14% of the world population), there are many critical issues in the management and care of patients with this form of headache: the shortcomings concern the multi-faceted approach and interdisciplinary, medical references at a territorial level, and homogeneous diagnosis, therapy and assistance paths.
Even though there are national and international guidelines that guide the diagnosis and treatment of headaches in childhood, the critical passage between prepuberty and postpuberty is not adequately followed with attention, we read in a report presented in Rome on the first results of the process for women. In the pediatric age it is necessary to focus attention on socio-environmental factors and on situations that represent sources of stress and which favor the onset of migraines. A combined social-behavioral and pharmacological intervention is only necessary when social and behavioral intervention is not effective.
Headaches in children, why they should not be underestimated by Elena Bozzola 06 June 2023
Menstrual migraine
Menstrual migraines, which appear 2 days before menstruation and continue for 3 days after the end of the flow, affect more than 50% of women “Women spend an hour and a half more in bed than their male peers and the 11% of headache suffers an impediment to social activities, for 14% of women with migraines their illness has affected their school choices”, he explained Piero Barbanti, director of the Unit for treatment and research on headaches and pain, Irccs-San Raffaele University of Rome and president of the Italian Association for the fight against headaches, Aic, during the meeting in Rome. A neurological specialist consultation is necessary if there are intense and prolonged symptoms to evaluate the case for prescribing specific drugs and menstrual prophylaxis, concluded the group of experts, of which Barbanti is part.
Menstrual cycles are not all the same by Sara Carmignani 04 August 2023
Contraception
“The type of migraine experienced by women on contraceptive therapy must be carefully evaluated – Barbanti continues – Migraine with aura (a particular type of migraine with attacks preceded by sudden flashes of light, ed.) represents, in fact, an absolute contraindication to use of estrogen-progestin oral contraceptives in relation to the increased risk of ischemic events. For women suffering from migraine with aura, progestin-only contraception represents the only indicated option”.
“There are girls who take birth control pills and their gynecologist doesn’t know that his patient is a migraine sufferer and has a thrombotic risk,” she said Fabio Frediani, director of the Neurology and Stroke Unit, San Carlo Borromeo hospital in Milan, and recalls that “a woman’s fertile period is also the active one, in professional, family and social terms, and is also the most disabling one”. To confirm the diagnosis of migraine with aura, a consultation between a gynecologist and a neurologist or headache specialist is necessary. In some cases, before choosing a contraceptive, the patient’s thrombotic risk must be assessed with adequate screening.
Pregnancy and breastfeeding
Today there are drugs considered safe that can be prescribed to pregnant or breastfeeding women, but for the treatment of migraines during these stages of life, consulting a neurologist or headache specialist is necessary. Self-administration of non-steroidal anti-inflammatory drugs (NSAIDs), as stated in the report, can be more harmful than the use of other anti-migraine drugs. “For 50-60% of migraine-prone women, the migraine improves during pregnancy, for 30% it does not disappear or subside and there is also a small group of patients for whom it worsens”, says Giovanni Battista Allais, responsible Women’s Headache Center, Department of Surgical Sciences, University of Turin and national councilor of Anircef, “A problem – continues Allais – because these women can count on few drugs in the event of an attack and also the molecules to prevent migraine attacks are few for these women”.
However, there is more and more evidence in favor of the effectiveness of acupuncture as a replacement or in association with drugs: pregnant women can resort to acupuncture, in short, but there are few centers that administer it, as specialists have pointed out – and very few those in the national health system.
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Assisted procreation
Medically assisted procreation (PMA) is a gray area in the treatment of women with migraine. Why shade? Because there is a lack of data in the literature, and there are no guidelines or recommendations. What we know, the panel of experts tells us, is that the hormonal stimulation necessary for egg retrieval causes migraine attacks or worsens symptoms. “Inducing ovulation requires a significant administration of hormones – continues Allais – and in fact in clinical practice there is a high dropout rate among women with migraines after the first attempt”. So? The presence of migraine should be carefully considered before undergoing PMA techniques and the gynecologist should consider the administration of alternative (lighter) hormonal stimulation protocols. Furthermore, heterologous fertilization could be a potential alternative, particularly for women of advanced age, is the idea of the experts of the Women’s Migraine Path working group.
Menopause
The phase around menopause must be carefully monitored to avoid strong hormonal fluctuations that can trigger attacks. “Women who suffered from menstrual migraines can improve with menopause – explains Frediani – but in the transition phase, the climacteric, there can be a worsening, in any case with menopause for one in three women with migraines the situation does not change”. For those over 50, migraine is the leading cause of disability.
Oncology patients
Most oncological treatments – surgical and pharmacological – are associated with worsening migraines. The worsening is particularly evident with hormonal treatments for breast cancer. Therefore it is necessary that the oncologist carefully monitors the situation and that there is a direct connection with the neurologist or headache specialist.
What to do if you suffer from headaches
“Taking good care of a woman, and a patient in general, who suffers from headache means getting her to the right place at the right time, and at the beginning the best place can be the general practitioner – he says Cinzia Finocchi, director of the complex neurology structure, San Paolo hospital in Savona and president of Anircef -. For many people, a good overview and good indications from your doctor are sufficient. The doctor, if he is part of a network and if he is trained to do so, knows how to frame the problem, understand what headache that person suffers from and then, if necessary, he can manage it himself, or he can refer him to the neurologist of local medicine . The most complex cases are moved to the third level: the headache center. In Italy we have around 250 headache centres, they are not few, although distributed unevenly”.
But are things like this? “Things are going very irregularly: today in Italy we are very patchy” continues Finocchi. There are areas of the Peninsula where these routes are well structured and others where they are not at all, where they do not exist. And patients arrive at headache centers a bit at random, perhaps because they have heard about them and it happens that they are people who could have been intercepted and treated earlier, elsewhere not in the centres”.
Among women there are patients who suffer from more complex and difficult to treat forms of headache, it is clear that the percentage of patients who should refer to headache centers is greater than the percentage of men. “It is like this – confirms the expert – and women more than men need a multidisciplinary approach, an interaction between a general practitioner, gynecologist, neurologist or headache specialist. Today we have many drugs capable of treating even the most complicated migraines, recent years have truly revolutionized the treatment of this pathology.”
Customize routes
“We are committed to ensuring that all people who suffer from headache in Italy find an adequate response to their health problem and that scientific research resolves uncertainties and unmet needs. The fundamental inspiring principle of the model dedicated to women with migraines, developed in collaboration with Onda – concludes Finocchi – it is the personalized approach to management and treatment that takes into account individual variability in terms of genetic characteristics, environment, lifestyles and personal experiences”.