Migraines occur two to three times more in women than in men. Migraines are the most common cause of disability in women ages 15 to 49. It has a much more significant impact on women's professional careers than on men's. No other disease is responsible for more years of healthy life lost in women during their active working years. Not only are migraines more common in women, but the attacks are also more severe. They last longer and the accompanying symptoms are stronger. And they respond less well to therapy. There are many aspects of women's lives that need to be considered when treating migraines.

The so-called menstrual migraine

The term menstrual migraine can be found in many publications on the subject of headache. It is used so naturally that for many years hardly anyone questioned it. Some people even believed that migraines were always somehow related to menstruation. Migraines were considered a women's disease .

However, research has shown that the taken-for-granted connection between female hormones, menstruation, pregnancy, menopause, birth control pills and migraines needs to be put into perspective.

Migraine attacks that occur exclusively during menstruation are extremely rare . After detailed questioning, those affected almost always remember that they suffer from migraine attacks not only during menstruation, but also at other times in the cycle.

The term menstrual migraine would only make sense if it were used to describe migraine attacks that occur exclusively in connection with menstruation. If you add the three days before and after menstruation to the menstrual period, you can see that a maximum of one in 20 women who meet the criteria for migraine belongs to this group. The term menstrual migraine can therefore only be used for a small proportion of affected patients.

Likewise, a connection with the so-called premenstrual syndrome has not yet been scientifically proven. This syndrome, characterized by abdominal pain, weakness and other psycho-vegetative symptoms, appears about two to three days before menstruation.

Migraine attacks related to menstruation do not differ from other migraine attacks, even though menstrual migraine is often a particularly severe and long-lasting attack that is accompanied by very severe nausea and vomiting. However, any form of migraine with or without aura can occur during menstruation. If menstruation is actually a triggering factor, the migraine attack is usually triggered two days before menstruation.

In patients who only experience migraine attacks during menstruation, there is often a fixed time relationship between the attacks and menstruation. However, in other women this timing may be loose and the migraine attack may occur at different intervals from menstruation.

Relationship between menstruation and migraines

It is known from clinical and experimental studies that migraines associated with menstruation are triggered drop in estrogen and progesterone levels Accordingly, the drop in plasma estradiol levels can probably be blamed for triggering the migraine attack. The absolute hormone levels, on the other hand, do not seem to be important. The possible cause of the headache during the drop in estradiol is assumed to be an effect of the hormone on the vessels, with vasodilatation due to the lower hormone concentration being suspected.
Further analyzes of the hormone concentrations have not yet yielded a uniform opinion on the importance of the various hormones in triggering migraine attacks. Neither the follicle-stimulating hormone (FSH nor the luteinizing hormone (LH) differ between patients suffering from menstrual-related migraine and healthy controls. Treatment of menstrual migraine

Due to the temporal connection with menstruation, it made sense to use hormonal therapy methods. The administration of estrogen three to 10 days before menstruation was previously recommended. However, it turned out that this only postpones the start of the migraine attack until the natural drop in hormones occurs again.

The use of hormonal patches that release estrogen through the skin has also not been shown to be effective in controlled studies. The same applies to the administration of estrogens in tablet form.

Pregnancy and migraines

Influence each other

Migraines are of particular importance for an intended or existing pregnancy because of the following questions:

  • How is a migraine treated during pregnancy?
  • Which medications are indicated or contraindicated?
  • Is pregnancy threatened by migraine disease?

What effects can pregnancy have on the course of the migraine attack?

Fortunately, it has been shown that pregnancy has positive influence In fact, there is hardly a better prophylactic measure.

It is known from epidemiological studies that almost 70% of affected patients experience a significant improvement or even a complete absence of migraine attacks during pregnancy. The effect on the course of migraines is particularly evident in the last two thirds of pregnancy. Studies have not yet clarified whether the positive effect on migraines gradually decreases with repeated pregnancies.

Only a small proportion of patients experience a constant progression or even a worsening of migraines during pregnancy. This seems to be particularly true for patients suffering from migraines with aura. If migraine attacks occur for the first time during pregnancy, they are primarily migraines with aura. However, this is only the case for a minority of those affected; according to a French study in 13% of the patients examined. After delivery, around half of the patients experience a recurrence of headaches in the first week, predominantly of the tension type, but also migraine attacks.

Improvement in the course of migraines

The cause of the sometimes spectacular improvement during pregnancy is still completely open. However, various hypotheses are discussed:

  • On the one hand, it is believed that the constantly increased concentrations of estrogen and progesterone during pregnancy cause the improvement.
  • Other explanations assume that altered serotonin metabolism during pregnancy and an increased concentration of endogenous opioids, i.e. opiate-like substances produced by the body itself, are responsible for the improvement.
  • In any case, the changed lifestyle during pregnancy seems to be of crucial importance. Pregnant women eat more consciously, have a regular sleep-wake cycle, avoid alcohol and nicotine, try to live less stress and are less stressed in the work process. There is a pregnancy-related control of trigger factors and accordingly fewer migraine attacks are triggered. However, there are no empirical studies that confirm this hypothesis.

Migraine prevention during pregnancy

In general, drug therapy should be avoided during pregnancy if at all possible. Of course, this particularly applies to prophylactic measures where medication must be taken daily. The migraine prophylactics that have proven to be particularly effective are contraindicated during pregnancy. This applies to beta-receptor blockers, flunarizine, serotonin antagonists, tricyclic antidepressants and especially antiepileptic drugs. This is particularly important if a pregnancy is planned or even suspected. Since young women in particular use such medications for severe migraines, they must be made aware of the need for adequate contraception.

To prevent migraine attacks during pregnancy, as usual, behavioral measures such as:

  • relaxation exercises and
  • Getting to know and avoiding trigger factors.
  • If migraines are severe during pregnancy, especially migraines with aura, administration of magnesium for migraine prophylaxis can first be considered. The effect of magnesium on the course of migraines has generally been shown to be small in clinical studies, but in individual cases a significant effect can be achieved.
  • Propranolol is used to treat arterial high blood pressure during pregnancy . There is no evidence of a fetal disorder. Nevertheless, the use of propranolol during pregnancy to prevent migraines should be carried out very cautiously and should only be considered as a last resort.

Treatment of migraine attack during pregnancy

There is very little literature on the effectiveness and tolerability of medications for the treatment of migraine attacks during pregnancy. The same applies to the effects of medicinal migraine therapy on childbirth and breastfeeding.

Non-steroidal anti-inflammatory drugs such as ibuprofen or diclofenac should only be used in exceptional cases and only in the 2nd trimester of pregnancy.

Paracetamol has long been considered the analgesic of first choice in pregnancy, but is increasingly associated with later health problems in the child (increased risk of bronchial asthma, disturbance of the child's psychomotor development or cryptorchidism in boys). However, the data currently does not allow a final assessment of the risks. In view of the low effect of paracetamol on migraines, the use of the substance during pregnancy is currently no longer recommended (see below).

not during pregnancy . On the one hand, there is insufficient experience, and on the other hand, it has not been proven that they end migraine attacks more effectively than the above-mentioned substances that have been used for many decades. Particular care must be taken to ensure that nonsteroidal anti-inflammatory drugs are not used continuously. Particularly during the last trimester of pregnancy, there is a risk of prolongation of the pregnancy, an increased risk of preeclampsia, an increased risk of bleeding for mother and child and an increased risk of persistent pulmonary hypertension in the child.

Warning about paracetamol during pregnancy

New studies describe a possible link between exposure to paracetamol before birth and increased risk of asthma, other respiratory diseases and impaired testicular development.

Paracetamol was previously considered the safest painkiller during pregnancy. Based on previous data, safety appeared to be beyond doubt. Pregnant women were recommended to take this painkiller almost without hesitation if they had pain during pregnancy. However, based on recent studies, careful rethinking of this recommendation is necessary. New studies describe a possible link between exposure to paracetamol before birth and increased risk of asthma, other respiratory diseases and impaired testicular development. Disturbances in the child's psychomotor development are also discussed. Contrary to previous recommendations, it is therefore not recommended to take paracetamol in mono- and especially combination preparations if you are pregnant or are already pregnant.

Until the exact connection is clarified, the principle must apply: In case of doubt, for the unborn life and against taking paracetamol, especially in combination with other painkillers.

Due to the new data, short-term benefits and long-term lifelong risks are no longer balanced in the case of possible or existing pregnancy.

The use of paracetamol by the pregnant woman and the unborn child's exposure to the drug appear to lead to a significantly increased risk of developing asthma and respiratory diseases in children and possible infertility in boys. In recent years there has been a significant increase in the frequency of asthma globally. Paracetamol is one of the most commonly used medicines in Germany. Paracetamol can lead to a reduction in glutathione in the lungs. Glutathione is believed to play an important role in the development of asthma.

According to new study results, the well-founded suspicion of a significantly increased risk of developing the positional anomaly of the testicle in boys (cryptorchidism) is particularly worrying. For those affected, this can later lead to reduced fertility and an increased risk of developing malignant testicular tumors. Sperm count and sperm vitality in later life may be reduced. The combined use of two painkillers in pregnant women was associated with a 7-fold increased rate of cryptorchidism in newborn boys. It is suspected that the effects of one 500 mg tablet of paracetamol could be more harmful to the unborn child than the ten most common environmental pollutants. The studies were criticized because a causal connection had not yet been definitively proven.

Paracetamol was previously considered a safe, harmless, tolerable and inexpensive painkiller in therapeutic doses. The risk that an overdose of more than 150 mg per kg of body weight can trigger irreversible liver cell damage and even liver failure has already led to a limitation in the pack size in the context of self-medication. The new studies justified a significant rethinking of its use in possible, planned or existing pregnancy.

In general, you should avoid taking painkillers during pregnancy and breastfeeding. In individual cases, if the pain is particularly severe, acute medication can be considered after medical advice. However, it must be taken into account that so-called simple painkillers such as paracetamol only have a weak and short effect on the severe attack of pain, but at the same time can cause lasting lifelong risks for the unborn child.

Contrary to previous recommendations, it is therefore not recommended to take paracetamol in mono- and especially combination preparations if you are pregnant or are already pregnant.

Triptans

The company pregnancy register has not yet shown a significantly increased risk of malformations when using sumatriptan in the first trimester of over 1000 pregnancies.

For the other triptans, there is insufficient data to assess the safety in pregnancy. not be used during pregnancy

Ergot alkaloids such as ergotamine tartrate and dihydroergotamine are strictly contraindicated. The substances have a uterotonic effect during pregnancy. In addition, ergotamine has a toxic effect on the embryo.

Treatment of migraine attack during breastfeeding

Painkiller

Ibuprofen is the analgesic of choice during breastfeeding. When taken sporadically, it only passes into breast milk in very small amounts and is even approved for the treatment of newborns.

Triptans

Triptans pass into breast milk. For sumatriptan, the specialist information recommends a 12-hour break from breastfeeding after taking it, and 24 hours for all other triptans.

Behavior when you want to get pregnant

  • In the first 14 days after the first day of the last menstrual period (assuming a regular 28-day cycle (!)) it can be assumed that there is no pregnancy.
  • With a regular cycle, ovulation occurs approximately 14 days BEFORE menstruation.
  • Six days after ovulation, the fertilized egg implants in the uterus and thus the first contact between “mother and child”.
  • Migraine attacks can be treated with medication for approximately the first three weeks after the first day of the last menstrual period without endangering the fetus.
  • An existing pregnancy can be diagnosed with newer pregnancy tests from the 6th to the 10th. The day after ovulation can be detected, which means there are some “unsafe” days around three weeks after menstruation in which it is recommended to carry out a pregnancy test before taking acute medication.

Birth control pills and migraines

In the case of persistent migraine attacks that are difficult to treat, birth control pills are often blamed for triggering the attacks. Empirical testing of a connection between birth control pills and migraines, on the other hand, does not show a clear connection: some studies speak of an actually increased occurrence of migraine attacks, although this is said to be the case in 18-50% of affected patients, depending on the study. In other studies, therapy with the contraceptive pill actually shows an improvement in migraines in up to 35% of patients. In so-called double-blind studies, however, no significant difference was found between groups of patients who were treated with the contraceptive pill or placebo.

All in all, it appears that there is no definitive connection between the birth control pill and migraines.

The treatment of migraines does not differ if you are taking a contraceptive pill or not. Birth control pills and migraine medications are also not known to affect each other. When carrying out migraine therapy, the same guidelines apply as usual.

It is only advisable to try skipping the contraceptive pill for migraines, which occur rarely and do not respond to drug therapy. The patient should then be recommended another method of contraception.

Because of the increased risk of arterial or venous cerebral thrombosis and cerebral hemorrhage, a neurological examination should be carried out as soon as possible if neurological disorders suddenly occur.
This also applies when unknown headache attacks occur. For this reason, patients who take birth control pills in particular should be monitored at closer intervals to see how the disease is progressing. Smoking should be strictly avoided. This is particularly true due to the possible increased risk of stroke with migraine disease. Overall, however, this risk of an increased frequency of strokes with migraine is extremely low. Migraine is therefore in no way a contraindication to the use of oral contraceptives. Menopause and older age

It is often the opinion that migraines gradually “burn out” as we get older, i.e. their frequency and intensity decrease. However, studies that deal with this complex of questions show that in more than 50% of those affected there is no change in the previous course of migraines . Around 47% of patients even experience a deterioration.

The increased frequency of migraines in women compared to men also persists in old age. Hormone therapies in old age cannot influence migraines. Accordingly, in this age group, migraine therapy should be carried out as usual.

However, beyond the age of 75 or 80, a change appears to occur. In fact, there are hardly any patients in the specialized migraine outpatient clinics who are older than 80 years and complain about migraine attacks.