17 January 2005

Stopping the monthly headache cycle

Call it an ounce of prevention that could be the salvation for many women who suffer migraine headaches during their menstrual cycles

Call it an ounce of prevention that could be the salvation for many women who suffer migraine headaches during their menstrual cycles.

The "miracle" treatment? Small doses of a prescription drug that's already marketed to combat existing migraines, according to Dr Newman, director of the Headache Institute at St Luke's-Roosevelt Hospital Centre in New York City.

Newman was the lead investigator on a study that found that tablets of naratriptan hydrochloride, a medication sold under the brand name Amerge and designed only to stop an existing migraine, were effective in stopping menstrual migraines before they began.

Newman, who himself suffers from migraines, began investigating the possible preventive use of several headache medications on menstrually related headaches four years ago. The results of his first trial were so promising that he asked Glaxo Wellcome Inc, the manufacturer of Amerge, to sponsor a larger study involving 18 centres nationwide.

He considers the results of the second study, involving 206 women and completed last year, both promising and surprising, although more research is needed.

The best results occurred for those women in the study who took a low dose of Amerge, one-milligram tablets twice a day for five days beginning two days before the onset of their periods. Almost one in four - 23 percent - remained headache-free throughout four menstrual cycles, which was the length of the study.

Those women in the study who received placebos had only an eight percent success rate.

But the researchers were astounded to find that other women in the study who had been given higher doses of Amerge - 2.5 milligrams, or the normal dose for an existing migraine - also had only an eight percent success rate.

"We were shocked," Newman concedes, noting that he had expected the higher doses to be at least as effective as the lower doses of the medicine. "I've laid awake many nights trying to understand how this could be."

The migraine-menstruation link

While he still can't explain it thoroughly, he does believe that the medication, when taken preventively, is necessary in only small amounts to change a woman's propensity for menstrual migraines. Other migraine medications similar to Amerge, collectively known as triptans, could have the same results, he adds.

Menstrual migraines account for 60 percent of all migraines in women, researchers say, even though they're not recognised as a specific migraine subtype by the International Headache Society.

Neurologists have long believed that migraines are connected to the menstrual cycle, a connection that was recently confirmed at the Thomas Jefferson University Hospital Headache Centre in Philadelphia.

In a study conducted over three months last year at the Headache Centre, the centre's director, Dr Stephen Silberstein, found that women are twice as likely to experience migraines during the first two days of their menstrual cycle than during the rest of the month. His study also found a higher risk of migraines in the two days before menstruation begins, as well as a lower risk around the time of ovulation.

The study was one of the few that looked at the relationship between migraines and menstruation in the general population, as opposed to only patients in headache clinics, and one of the first to ask whether migraines during menstruation are different in length and pain than during other times.

The good news is that although menstruation is a powerful trigger for migraines, the menstrually related versions are no more severe than "those triggered by alcohol and chocolate," Silberstein says. His study was sponsored by Astra Zeneca Pharmaceuticals, manufacturer of Zomig, generically known as zolmitriptan, another migraine medication.

Migraines are caused when levels of the neurotransmitter serotonin in the brain sink too low, Newman says. The headaches have been described by those who get them as similar to repeated blows from a hammer, and the throbbing, debilitating pain can leave many sufferers unable to function.

Most migraine sufferers are women

While menstrual migraines can be terribly debilitating for the women who endure them, their predictable nature actually can be a help in managing them, neurologists note.

Until the past decade, the treatments for migraines were limited. But now physicians have the triptans, a relatively effective class of drugs, in their arsenal. Triptans, which in addition to Amerge and Zomig include Imitrix and Maxalt, are designed to mimic serotonin. They connect to receptors in the brain and relieve the pain, nausea, sensitivity to light, sound and smell that characterize a migraine.

"If women have a better idea when they'll get a migraine during their cycle, they have a better chance to prevent or treat it," explains Silbersten, who also participated in Newman's study on Amerge.

Like Newman, he considers the medication a potentially life-changing option for women with menstrual-related migraines.

"It should become a standard treatment," he says.

But because triptans such as Amerge are presently marketed only for the treatment of migraine attacks, the manufacturer cautions that more research is needed to determine the efficacy and safety of using the drug preventively.


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Headache expert

Dr Elliot Shevel is a South African migraine surgery pioneer and the founder and medical director of The Headache Clinic in Johannesburg, Durban and Cape Town, South Africa. The Headache Clinic is a multidisciplinary practice dedicated to the diagnosis and treatment of Primary Headaches and Migraines. Dr Shevel is also the main author of all scientific publications generated by his team. He recently won a high level science debate in which he was able to prove that the current migraine diagnosis and classification is not based on data. Tertiary Education - Dr Shevel holds both Dental and Medical degrees, and practises as a specialist Maxillo-facial and Oral Surgeon. Follow the Headache Clinic on Twitter@HeadacheClinic.

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