Migraine and Estrogen
Migraine and Estrogen
Although accumulating evidence supports a role for sex hormones in headache, and particularly migraine, much about the specific mechanisms of how sex hormones affect migraine remains unknown. As estrogen can extend its impact in a variety of systems, its role in headache is likely multifactorial, including direct cellular and genetic modifications in the CNS, as well as potentially as a result of its effect on mood and pain perception. Furthermore, the relationship between various sex hormones (i.e. estrogens and testosterone) is complex, and future studies focusing on the association between these sex hormones and headache must take into account these interactions.
In addition to pain, migraine aura is affected by sex hormones. Although human studies have demonstrated a reduction of aura with extreme low-dose CHC, experts stress the importance of inhibition of ovulation as a critical precursor to reduction of aura (so that the ultra-low doses of these new regimens do not simply augment the endogenous fluctuating hormone levels). As many women are denied therapy with CHCs, in part because of published guidelines from the American Congress of Obstetricians and Gynecologists (ACOG) that recommend against their use in migraine with aura, as well as the lack of formal statement or guidelines from the International and American Headache Societies, Calhoun et al.'s recent study demonstrating decreased aura frequency with one of the new ultra-low-dose regimens may: point to more individualized treatment plans; stimulate larger, confirmatory trials to establish the safety of CHC use in MwA; and open discussions between the American and International Headache Societies and ACOG on revisions of ACOG's published guidelines.
Therapeutic Considerations and Future Directions
Although accumulating evidence supports a role for sex hormones in headache, and particularly migraine, much about the specific mechanisms of how sex hormones affect migraine remains unknown. As estrogen can extend its impact in a variety of systems, its role in headache is likely multifactorial, including direct cellular and genetic modifications in the CNS, as well as potentially as a result of its effect on mood and pain perception. Furthermore, the relationship between various sex hormones (i.e. estrogens and testosterone) is complex, and future studies focusing on the association between these sex hormones and headache must take into account these interactions.
In addition to pain, migraine aura is affected by sex hormones. Although human studies have demonstrated a reduction of aura with extreme low-dose CHC, experts stress the importance of inhibition of ovulation as a critical precursor to reduction of aura (so that the ultra-low doses of these new regimens do not simply augment the endogenous fluctuating hormone levels). As many women are denied therapy with CHCs, in part because of published guidelines from the American Congress of Obstetricians and Gynecologists (ACOG) that recommend against their use in migraine with aura, as well as the lack of formal statement or guidelines from the International and American Headache Societies, Calhoun et al.'s recent study demonstrating decreased aura frequency with one of the new ultra-low-dose regimens may: point to more individualized treatment plans; stimulate larger, confirmatory trials to establish the safety of CHC use in MwA; and open discussions between the American and International Headache Societies and ACOG on revisions of ACOG's published guidelines.
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