OVERVIEW
of the HORMONAL &
MEDICAL TREATMENT of
WOMEN’S HEADACHES

Edward Lichten, M.D.,PC
180 East Brown Street
Birmingham, MI 48009 
248.593.9999

INTRODUCTION
Focus on Menstrual and Menopausal Migraine
Hormonal changes particularly around the menstrual cycle, the use of birth control pills, the hormonal changes which occur during the first trimester of pregnancy, or the use of exogenous estrogens in the menopause are the most widely known hormonal triggers of migraine headaches. That is why, Doctor Edward Lichten, Director of the Headache Institute for Women in Birmingham, Michigan notes that women report almost 80 percent of their worst headaches to be associated with an hormonal event; these occurrences are most likely to be unresponsive to standard headache medication.

It is likely that the changes in estrogen levels prior to the onset of the menstrual period is responsible for the premenstrual migraine, the most common type of migraine a woman experiences. Almost 70 percent of women report migraine or their most severe headaches within 7-10 days of the beginning of menses. Birth control pills, because they alter estrogen levels, are known to aggravate migraine predisposition, and with their discontinuance, often migraine lessen. The same is true with the menopause in women who are using interrupted estrogen replacement therapy. When such medication is discontinued, these women frequently witness relief of head pain. And because estrogen levels change drastically within the first trimester of pregnancy, women who are sensitive to hormonal fluctuations may experience headache..

Menstruation and Premenstrual Syndrome
Dr. Lichten reports that for many women, these incapacitating migraines can be considered as one aspect of the condition known as premenstrual syndrome( PMS). It is believed that up to 40 million women note headaches and other premenstrual complaints such as crying spells, fatigue, backache, irrational behavior, feelings of anxiety and depression, panic attacks, cyclic weight gain, and food cravings. Dr. Lichten notes that neurologists recognize that women have many more complaints about headache than men and that their headaches often fail to respond to standard medications. "It is interesting to recall," Dr. Lichten explains, "that for centuries it has been recognized that boys and girls under eleven and men and women over fifty-five have a similar incidence of headache complaints. Only during the reproductive years do women report more than 80 percent of all headaches. Also, up to 70 percent of women note their worst headaches occur only in association with their menstrual periods."

Women on occasion will suffer migraine attacks at ovulation which occur midway through the menstrual cycle. In a significant number of women, pregnancy seems to alleviate migraine headaches, especially the second half of pregnancy when hormonal level s do not fluctuate. There is no definite explanation, but researchers including Dr. Lichten, are identifying new relationships between genetics, hormonal levels, premenstrual syndrome and migraine..

Lichten teaches that a woman’s cycle is influenced by its two separate hormonal components: estrogen and progesterone. Furthermore, the two weeks between the onset of menstruation and ovulation is called the follicular phase. The two weeks after ovulation is identified as the luteal phase. The two female hormones, estrogen and progesterone, fluctuate markedly during the last half of the menstrual cycle.

Estrogen levels are lowest during menstruation. Estrogen rises rapidly near mid-cycle only to fall just prior to ovulation. Over the next two weeks there is a second gradual rise and fall again of estrogen. Progesterone is produced only after ovulation. Peak progesterone and estrogen levels are reached about the twenty-third day, about five days before menstruation.

Dr. Lichten confirms previous research that the fall in estrogen levels which occur prior to menstruation is the trigger for many of women’s headaches. His medical publications confirm that the elimination of these estrogen peaks, just like the elimination of food triggers in dietary migraine, can prevent even the most severe forms of cyclic migraine in many women.

Medical Management of Hormonal Migraine
In an innovative study which Dr. Lichten conducted in 1986, he substantiated his belief that changes in estrogen levels during the menstrual cycle do, in fact, trigger headaches. Women who did not respond to standard headache medications were given an anti-estrogen medication to partially suppress cyclic estrogen production. This anti-estrogenic compound tricks the brain into thinking the body has too much estrogen, so the pituitary gland does not signal the ovaries to produce more. Thereafter, estrogen levels stabilize and in a majority of original and subsequent patients, migraine diminished.

Many neurologists recognize that hormonally related migraines remain the most difficult to treat. They also recognize the failure of several combination drug therapies, including the most recent injectable agents, for these women. The success of hormonal suppressive therapy for such patients supports the concept that for many women these migraines are a hormonally triggered event. At present, Dr. Lichten finds three anti-estrogenic compounds beneficial for migraine prevention.

In his publications, Dr. Lichten reconfirmed that hormonal suppression in the reproductive years would be effective for the most severe migraine conditions. Using three different anti-estrogenic methods, he was able to document the near elimination of migraine with each of these agents in more than 50 percent of women migraineurs. And the relief continued for years.

Menopausal Migraine
In a yet other published study, Dr. Lichten was able to elucidate one of the major causes of women’s menopausal migraines. He was able to document almost the exact blood level of estrogen that correlated to the migraine attack. By keeping the estrogen levels above this “headache threshold,” he prevented menopausal migraine in all his study participants. Since only some women get migraine in the menopause, and since they are uniformly the ones suffering with migraine in the pre-menopausal years, his data is the first to give credence to the concept that some women have a genetic defect which makes them sensitive to falling estrogen levels. Therefore, when one identifies this drop off estrogen point in combination with the genetic defect, migraine occurs. This explains why there are so many more migraine attacks in families with a strong history of severe headache.

Dr. Lichten has reconfirmed the findings of previous gynecologists that the medroxy-progesterone acetate used in menopausal women to prevent bleeding, can, in fact, be the cause of repeated severe headache attacks. He also supports that an MRI or CT scan of the brain should be conducted on women who report the sudden onset of severe headache or migraine in the late 50’s and later. Pathology must be ruled out in these cases prior to exploring a hormonal link.

But Dr. Lichten respects that no one individual has all the answer to every woman’s headaches. That is why, in association with many other Oakland County health professionals, a program has been developed so that physicians and auxillary staff may work together to find the best treatment for the difficult headache patients. In very select cases, hospitalization can be arranged.

Muscle Contraction Headaches
The most common headache is the muscle contraction or tension headache. While the migraineur suffers with headaches that are one-sided, pulsating in character, occurring for only a few days per month, and associated with nausea and vomiting, muscle contraction headaches usually are different. These headaches are almost daily, affect both sides of the head and neck and are described as tightening and contracting in character. There is an achy characteristic to the tension headache as well. Muscle contraction headaches occur twice as frequently and often co-exist with migraine.

Women Predominate
Why do women have more tension-type headaches then men? Although it has been argued that women suffer from more stress and are prone to repress their psychological pain into "headaches", I feel that it is a woman’s hormones and body structure that contributes to more tension headaches.

First, women have an increase in fluid retention as estrogen levels rise premenstrually. This fluid retention causes both muscle aching and denser breast tissue. The fluid retention in the trapezoid muscles of the shoulders can cause the muscle contraction headaches and stiff necks. Meanwhile, the heavier breast tissue and narrow brassiere support straps put more forward tension on these same muscles. With weaker trapezoid muscles and the increased discomfort, women round their shoulders forward, putting additional stress on the neck muscles. This forward head position from poor posture is the most common cause for the muscle contraction and tension-type headache.

Self Diagnosis
The diagnosis can be made by having someone observe the sufferer while sitting and standing. Looking down from above, the observer may note that this person is unable to turn her head to face over each shoulder. She may not be able to bend her ear down to her shoulder, and, may appear to have rounded shoulder when viewed from the front. To confirm the head forward position, have the observer note the position of hanging earrings. If the earrings are normally far forward of the line between the neck and shoulder, then the woman exhibits the abnormal "head forward" position and is more likely to suffer with muscle contraction headaches.

Treatment
Although this diagnostic technique is easy, the treatment is difficult and requires medical intervention. Treatments used in Dr. Lichten’s practice include muscle relaxers, diuretics, anesthetic blocks and physical therapy. The physical therapy includes home programs for muscle exercises, stretching and reposturing. A ‘posture’ bra is usually worn all day long to maintain a shoulders back posture. Medical therapy is usually for a short period of time, although medications and physical therapy may be required on a periodic basis.

Analgesic Rebound Headaches
Taking daily or almost daily over-the-counter medications or ingesting daily caffeine preparations makes the physician suspicious that the patient is suffering from "analgesic rebound" headaches. Such patients frequently start out with migraine, only to end up, years later with chronic daily headache. The presenting headache may be due to over use of medication. Whatever the underlying factor, these patients are the most difficult to diagnose and treat

With the co-existence of migraine and muscle tension headache in as many as two-thirds of sufferers, these symptoms often effect how the individual functions. With daily or almost daily headaches and the use of medication, these individuals often report depression and sleep disturbances. There may be significant underlying, stressful family dynamics.

The first step in dealing with analgesic rebound headaches is to stop the daily use of these drugs. Many facilities resort to hospitalization. Patients must understand that drugs used regularly contribute to headaches. With their discontinuance, the patient often experiences significantly less headaches.

In the practice of Dr. Lichten, he often incorporates a series of occipital nerve blocks in the treatment of muscle-contraction, analgesic rebound, and cervicogenic headaches. At the same time treatment is directed toward the underlying factors.

The management of headache disorders is complicated by many intertwining factors. When simple medical treatment fails to control these disorders, a careful evaluation of the possible underlying hormonal, postural and medication is needed. Working with other health professionals in Southeastern Michigan, an attempt is being made to bring additional relief to these difficult headache suffering individuals.

Summary
Recent research has confirmed the strong role hormones play in menstrual or “hormonal” migraine, premenstrual tension, and muscle contraction headaches. For women’s headaches are uniquely influenced by changing hormonal levels and biomechanical differences in body structure. We can truly state that with this knowledge, many women will find that next month can be better!

Finding the Best Approach
In treating migraine, muscle contraction headaches and those related premenstrual symptoms, Dr. Lichten suggests that oral contraceptives and multiple drug therapies are often not helpful. The best method for diagnosing and treating these conditions is to have good records of the symptoms, medication used (including over-the-counter medications and caffeine), and the relationship to the menstrual cycle. Coupling this with a mild diuretic, additional magnesium and vitamins and dietary restriction of dairy and red meats may offer significant headache relief.

With newer migraine drug treatments, many women can expect to find relief of their disabling symptoms. Ongoing medical research offers these sufferers hope and an understanding of conditions long though to be psychosomatic in nature.

1. Lichten, E.M.The Efficacy of Danazol in the Treatment of Hormonal Migraine. J Reproductive Medicine,1991;36(6):419-425.

2. Lichten, EM, Lichten JB, Whitty A, Pieper D. The Use of Leuprolide Acetate in the Diagnosis and Treatment of Menstrual Migraine: The Role of Artificially Induced Menopause. Headache Quarterly, 1995;6(4):313-317.

3. Lichten E.M. Menopausal Migraine. The Menopause. Reid-Rowell Symposium. 1990.

4. Lichten EM., Lichten JB, Whitty A, Pieper D. The confirmation of a biochemical marker for women’s hormonal migraine: The depo-estradiol challenge test. Headache 1996;36(6):367-70:

5. Lichten, EM, Lichten SR. Estradiol subcutaneous pellet for the definitive diagnosis and treatment of hormonal migraine. Cephalgia 1999;19(4):332

 
Hormonal Headache

Muscle Tension Headache