Ilaria Castagnoli Gabellari

Non-pharmacological management of migraine during pregnancy

Migrainous women note a significant improvement in their headaches during pregnancy. However, persistent or residual attacks need to be treated, keeping in mind that many drugs have potential dangerous effects on embryo and foetus. It is evident, therefore, that hygiene and behaviour measures capable of ensuring the best possible well-being (regular meals and balanced diet, restriction of alcohol and smoking, regular sleeping pattern, moderate physical exercise and relaxation) are advisable during pregnancy. Among non-pharmacological migraine prophylaxis only relaxation techniques, in particular biofeedback, and acupuncture have accumulated sufficient evidence in support of their efficacy and safety. Some vitamins and dietary supplements have been proposed: the prophylactic properties of magnesium, riboflavin and coenzyme Q10 are probably low, but their lack of severe adverse effects makes them good treatment options.

The risks of women with migraine during pregnancy.

Most epidemiological studies demonstrate that women suffering from migraine note a significant improvement in their headaches during pregnancy. Both headache specialists and gynecologists commonly hold that migraine does not involve any risks to either the mother, or the fetus. Despite this, recent studies into the medical complications of pregnancy in migrainous women have cast doubts on this assumption. Indeed, most of these studies have revealed a significant association between migraine and hypertension in pregnancy (i.e. preeclampsia and gestational hypertension). Migraine has also been recently postulated as one of the major risk factors for stroke during pregnancy and the puerperium. Therefore, there is an urgent need for prospective studies on large numbers of pregnant women to determine the real existence and extent of the risks posed by migraine during pregnancy. In the meantime, while awaiting verification of this hypothesis, a pregnant woman with migraine must be subject to a particularly attentive screening by both the obstetrician and the headache specialist.

Oral contraceptives in migraine

Combined oral contraceptives are a safe and highly effective method of birth control, but they can also raise problems of clinical tolerability and/or safety in migraine patients. It is now commonly accepted that, in migraine with aura, the use of combined oral contraceptives is always contraindicated, and that their intake must also be suspended by patients suffering from migraine without aura if aura symptoms appear. The newest combined oral contraceptive formulations are generally well tolerated in migraine without aura, and the majority of migraine without aura sufferers do not show any problems with their use; nevertheless, the last International Classification of Headache Disorders identifies at least two entities evidently related to the use of combined oral contraceptives: exogenous hormone-induced headache and estrogen-withdrawal headache. As regards the safety, even if both migraine and combined oral contraceptive intake are associated with an increased risk of ischemic stroke, migraine without aura per se is not a contraindication for combined oral contraceptive use. Other risk factors (tobacco use, hypertension, hyperlipidemia, obesity and diabetes) must be carefully considered when prescribing combined oral contraceptives in migraine without aura patients, in particular in women aged over 35 years. Furthermore, the exclusion of a hereditary thrombophilia and of alterations of coagulative parameters should precede any decision of combined oral contraceptive prescription in migraine patients.

Menstrual migraine: clinical and therapeutical aspects

Estrogens fluctuations, particularly their premenstrual fall, are currently regarded as the main triggers of menstrual migraine (MM). MM presents in two clinical forms: pure MM, where attacks are confined to the perimenstrual period (PMP), and menstrually related migraine, where attacks always occur during, but are not confined to, the PMP. MM episodes are usually longer, more intense, more disabling and more refractory than nonmenstrual attacks. Acute management of MM should initially be abortive and primarily sought with triptans. If this fails, short-term perimenstrual prophylaxis with NSAIDs, coxibs, triptans or ergotamine derivatives can be considered. Hormone manipulations, mainly application of percutaneous estradiol gel in PMP or administration of oral contraceptives in extended cycles, constitute an alternative approach for nonresponders.

Sumatriptan (50 mg tablets vs. 25 mg suppositories) in the acute treatment of menstrually related migraine and oral contraceptive-induced menstrual migraine: a pilot study.

Migraine attacks are common in the perimenstrual period (menstrually-related migraine, MRM) and can be particularly exacerbated by the cyclic suspension of oral contraceptives (oral contraceptive-induced menstrual migraine, OCMM). This cross-over, randomised study evaluated the efficacy and tolerability of rectal (25 mg) and oral (50 mg) sumatriptan in the treatment of 232 menstrual migraine attacks (135 MRM and 97 OCMM). Two hours after suppository administration, 72% of patients in the MRM group achieved pain relief and 24% were pain free; after tablet administration, the percentages were 66% and 27%, respectively. In the OCMM group 55% of patients improved at 2 h with suppositories and 46% with tablets, 27% of patients were pain-free after suppositories and 18% after tablets. Fifty percent of patients given suppositories were pain-free at 4 h post-treatment and 47% of those given tablets. Sumatriptan also effectively alleviated symptoms associated with migraine, such as nausea, vomiting and photo/phonophobia. A single dose of medication sufficed for pain relief without relapse in 47.4% of the attacks (MRM: 66%; OCMM: 33%). Both formulations were well tolerated.

Migraine and stroke: the role of oral contraceptives.

The use of oral contraceptives (OCs) confers an increased risk for ischaemic stroke (IS). This risk slightly decreases, but remains significant, if low-dose formulations are used, particularly if other risk factors, such as hypertension or smoking, are associated. Some inherited prothrombotic conditions (e.g., Factor V Leiden, G20210A prothrombin or methylenetetrahydrofolate reductase C677T polymorphism) could also greatly increase the IS risk if present in OC users. Migraine, particularly with aura, is an independent risk factor for IS, and the patient’s IS risk is probably affected by other individual risk factors (e.g., age, genetic predisposition to thrombosis, presence of patent foramen ovale or enhanced platelet aggregation) which seem to be over-represented in migraine patients. IS risk among migraineurs is further increased when OCs are currently used and can become very high if associated with smoking. Consequently, in 2004 the WHO stated in its ‘Medical Eligibility Criteria for Contraceptive Use’ that women suffering from migraine with aura at any age should never use OCs. Moreover, since the exposure to the effects of OCs may greatly increase the IS risk in some migraine subpopulations with specific personal characteristic, testing for these risk factors may allow for more accurate stratification of the population at risk before long-term use of OCs is prescribed.

Oral contraceptive-induced menstrual migraine. Clinical aspects and response to frovatriptan

Oral contraceptive-induced menstrual migraine (OCMM) is a poorly defined migraine subtype mainly triggered by the cyclic pill suspension. In this pilot, open-label trial we describe its clinical features and evaluate the efficacy of frovatriptan in the treatment of its acute attack. During the first 3 months of the study 20 women (mean age 32.2±7.0, range 22–46) with a 6-month history of pure OCMM recorded, in monthly diary cards, clinical information about their migraine. During the 4th menstrual cycle they treated an OCMM attack with frovatriptan 2.5 mg. The majority of attacks were moderate/severe and lasted 25–72 h or more, in the presence of usual treatment. Generally an OCMM attack appeared within the first 5 days after the pill suspension, but in 15% of cases it started later. After frovatriptan administration, headache intensity progressively decreased (2.4 at onset, 1.6 after 2 h, 1.1 after 4 h and 0.8 after 24 h; p=0.0001). In 55% of patients pain relief was reported after 2 h. Ten percent of subjects were pain-free subjects after 2 h, 35% after 4 h and 60% after 24 h (p=0.003 for trend); 36% relapsed within 24 h. Rescue medication was needed by 35% of patients; 50% of frovatriptan-treated required a second dose. Concomitant nausea and/or vomiting, photophobia and phonophobia decreased significantly after drug intake. OCMM is a severe form of migraine; actually its clinical features are not always exactly identified by the ICHD-II classification. However, treatment with frovatriptan 2.5 mg might be effective in its management.

Ear acupoint detection before and after hysteroscopy: is it possible to clarify the representation of the uterus on the outer ear?

Background In the auricular maps introduced over the past 50 years by the French and Chinese schools, most organs and systems overlap consistently. One exception is the reproductive system, which shows a markedly different somatotopic representation—for example, for the uterus and the ovary. Objective To identify the distribution of points with increased tenderness to pressure or with reduced electrical resistance, on the outer ear of a group of women undergoing hysteroscopy. Methods For diagnostic purposes the auricles of 78 women were examined before and after hysteroscopy using a pain–pressure test and electrical skin resistance test. The points identified were transcribed onto a graphic system called Sectogram. Spatial cluster analysis was used to identify the statistically significant clusters of sectors with a higher concentration of points appearing after hysteroscopy. Results The points identified after hysteroscopy tend to be concentrated in specific areas not previously recognised and which only partially overlap with the French and Chinese representation of the uterus. Conclusion When auricular acupuncture is applied to reduce discomfort during hysteroscopy, particular attention must be paid when choosing the points/areas to be stimulated, which are not only those indicated in the Chinese or French maps.

Almotriptan for menstrually related migraine

Introduction: Approximately 50% of migrainous women associate their headache temporally to menses. Menstrually related migraine (MRM) is a disabling form of migraine characterized by attacks that are generally longer, more severe and less drug-responsive than nonmenstrual ones. Since MRM may be difficult to treat, it is important to find an appropriate treatment option for women suffering from this condition. Areas covered: This paper provides an overview of the clinical features of MRM, with special attention on the use of almotriptan for its treatment. Four studies on almotriptan in the treatment of MRM are present in the medical literature. Two report post hoc analyses of data derived from larger studies on the use of almotriptan for migraine treatment. One reports the results from a study specifically dedicated to MRM and one illustrates a subanalysis on the accompanying symptomatology. Expert opinion: Evidence demonstrates that almotriptan is a molecule with a high efficacy in the treatment of MRM and with an excellent tolerability profile when compared with other triptans. Moreover, it shows a proven ability to control migraine-associated symptoms. All these qualities play a decidedly positive role in making almotriptan a product of choice for the treatment of MRM.