Hormones and Migraine – What’s The Connection?

0:00 okay migraine Canada we are a federally
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0:04 Canadians living with migraine and
0:06 headache disorders our mission is to
0:08 improve the lives of Canadians with
0:10 migraine and other headache disorders
0:12 through advocacy awareness education
0:14 research and support
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0:25 our website also has an advocacy page
0:28 with useful tools to advocate for
0:31 yourselves and your loved ones who have
0:34 migraine and our website also has a
0:38 library with hacks or migraine
0:40 management
0:43 and we are very excited to be
0:45 collaborating during Women’s Health Week
0:47 2023 with the Women’s Health Coalition
0:50 on this webinar be sure to also check
0:52 out the two podcasts which will be
0:54 launched this week there are many
0:56 obvious reasons our organizations
0:58 support one another together we are
1:00 stronger and can improve health outcomes
1:02 for women and with that I’m going to
1:04 hand it over to Carmen to introduce the
1:07 Women’s Health coalition
1:15 thank you Kaylee
1:18 um I also am very excited to be here and
1:20 collaborating
1:21 um with migraine Canada I’ve been
1:23 working with uh Dr Elizabeth LaRue since
1:26 the very start of the Women’s Health
1:28 Coalition because uh my brain affects
1:33 women so much and it affects women who
1:36 are going through life changes and it’s
1:38 probably the number one complaint that
1:41 we get as an organization in terms of
1:44 the health system ability to support the
1:47 patient experience and so I’m excited to
1:49 be here with migraine Canada today as it
1:51 says our mission is to create a movement
1:54 to speak openly learn and engage with
1:56 purpose to address menstrual
1:58 reproductive and sexual health for life
2:01 through all the ages and stages of a
2:04 woman’s health Journey
2:05 our advocacy we are an advocacy
2:08 organization and our advocacy is enabled
2:12 by
2:13 um listening to women’s stories we’re
2:15 then informed by Healthcare professional
2:17 expertise and advanced by evidence-based
2:20 recommendations to government and health
2:23 system influencers and as of this spring
2:26 we became a National Organization so
2:28 working federally and in each province
2:31 across Canada addressing all elements of
2:34 women’s sexual reproductive and
2:37 menstrual health so thank you for
2:39 letting me join you this evening and I
2:41 look forward to learning more about
2:43 hormones and migraine
2:46 thank you Carmen
2:49 okay so quickly before we begin everyone
2:51 uh just our disclaimer that this webinar
2:55 provides information and not medical
2:57 advice please note that the information
2:59 presented and discussed might not apply
3:02 to your own medical situation always
3:05 discuss Medical Treatments with your
3:07 your own health care provider who knows
3:09 your medical history
3:11 and I’ve already mentioned this but
3:14 please post your questions throughout in
3:17 the Q a box
3:19 we will be answering the questions at
3:22 the end of the webinar and if there
3:25 happen to be any questions that we don’t
3:26 answer don’t worry we’re going to be
3:28 recording those and we’ll be posting
3:30 those questions with their answers on
3:33 social in the next couple of days
3:35 this webinar will be recorded and again
3:38 the entire webinar will be available for
3:40 viewing within a day or two
3:46 all right Dr Candace Todd is our
3:48 presenter tonight
3:50 Dr Todd is a general neurologist and a
3:52 headache medicine specialist at the
3:54 Scarborough Health Network in Toronto
3:56 she completed her residency at the
3:58 University of Toronto where she also
4:00 completed her Fellowship in headache
4:02 medicine
4:03 Dr Todd is interested in women’s health
4:06 issues and neurology specifically
4:08 pregnancy and its impacts on headache as
4:10 well as gender and racial disparities in
4:12 neurological diseases
4:16 okay Dr Todd over to you
4:21 I want to thank migraine Canada and the
4:23 women’s Coalition for allowing me to
4:25 speak on this topic
4:27 um obviously like it was mentioned
4:30 hormones and migraine are one of my
4:33 favorites I love helping women plan
4:35 pregnancy I love helping women manage
4:38 migraine during pregnancy because I know
4:41 a lot of women can do it successfully if
4:43 we plan and we choose the right
4:45 medications
4:46 um and so you know if there’s any
4:48 questions about pregnancy or pregnancy
4:51 planning I’m also very open to talking
4:53 about that as well I just want to
4:56 briefly talk about my disclosures which
4:58 have nothing to do with this talk but I
5:00 I do give talks for pharmaceutical
5:02 companies at times
5:05 so just in terms of presentation and
5:08 what are the things that we’re going to
5:09 talk about I first and foremost want to
5:11 just give a very brief overview about
5:14 migraine and the rules you know the
5:16 broad rules that hormones play in
5:18 migraine I’m going to focus also on
5:20 menstrual migraine and then the Hot
5:23 Topic which is perimenopause and
5:25 menopause and migraine and then how for
5:29 those individuals who are suffering from
5:31 migraine in the perimenopause menopausal
5:34 stage how can you Advocate and get the
5:37 help that you need
5:39 um and so that’s hopefully what I can
5:40 accomplish for you all this evening I
5:43 will say like mentioned before I’m not
5:46 going to really get into too much detail
5:48 about medications because really as I’m
5:51 sure you all can imagine medications are
5:52 very much a customized detailed
5:55 conversation between yourself and the
5:57 physician I am happy to talk you know
5:59 broadly about medications
6:02 um and then the other thing I want to
6:03 state is that this is largely you know a
6:06 mixed group of individuals that are that
6:08 are here for tonight so you know people
6:10 that may be in the healthcare profession
6:12 and a lot of people who aren’t so I want
6:14 to just keep it as relatable and
6:17 digestible as possible to everybody but
6:19 if there’s any more further details or
6:22 questions that people have I’m obviously
6:23 happy to answer them if I can
6:27 so the first thing is what role does
6:30 hormones play in migraine and I just
6:33 wanted to
6:34 dial it back a little bit and just make
6:37 sure that we all kind of understand what
6:40 the criteria is that Physicians use to
6:42 diagnose migraine I’m going to assume
6:44 that many of you on this webinar have
6:46 migraine are well versed in what
6:49 migraine looks and feels like
6:52 um but you know when you see a physician
6:54 often their job is to kind of listen to
6:57 your history as best as they can and see
6:59 if you meet this criteria so is the
7:01 headache one-sided well I see lots of
7:03 women who have migraine that do not have
7:05 a one-sided headache it has to be
7:08 pulsating it has to be severe you have
7:10 to want to lay down and rest and then
7:12 you can either have pieces of nausea or
7:15 vomiting or light and Sound Sensitivity
7:17 and if you have all of that then a
7:20 healthcare provider should be
7:21 comfortable with saying yes you have
7:23 migraine and here’s here are the things
7:26 that we are going to talk about I think
7:28 this is important to start off with in
7:30 this talk is because later on we’re
7:32 going to talk about how do you advocate
7:33 for yourself how do you get the best
7:35 care for yourself and one of those
7:37 things is often taking on some of that
7:39 role and you know making sure that
7:41 you’re
7:43 um talking to your healthcare provider
7:45 because many you know there’s lots of
7:47 research out there and you know migraine
7:49 is often uh under diagnosed because many
7:52 people don’t bring it up to their
7:54 primary care provider or they think that
7:55 there’s you know headaches or normal the
7:57 amount of time women come into my office
7:59 and say I’ve been suffering from
8:01 migraine since I was 8 or 12 and I just
8:05 thought it was normal and now they’re
8:06 30. that’s a huge amount of disease
8:09 burden time lost to a condition that
8:12 could be potentially treated so I just
8:15 wanted to put this slide up here for you
8:17 all to see
8:19 um
8:20 another few quick points just to kind of
8:23 give a broad overview we know that my
8:26 crane has a huge genetic kind of
8:29 underpin to it we only have a couple
8:32 genes that we’ve identified for certain
8:34 types of migraines but we what I say in
8:36 the office is that we think it’s
8:38 heritable we think that it is inherited
8:41 through the line of family members so
8:43 often in my office I say do your does
8:46 your mom have headache or migraine does
8:48 your grandmother do your kids because
8:50 it’s often runs pretty pervasive through
8:52 a family so there’s not just a genetic
8:55 or an inherited piece to migraine but
8:57 there’s also a huge environmental
8:59 component to that and that’s why you
9:02 know if you don’t sleep well you don’t
9:04 hydrate you don’t eat protein that can
9:07 often trigger trigger migraine many
9:10 migraine patients I call like my my
9:13 weather my Weather Vein because they can
9:15 tell me when rain is about to come they
9:17 can definitely tell me when all the
9:19 seasons are changing because they’re so
9:21 acutely tuned in to we call it
9:24 barometric pressure changes or pressure
9:26 changes in the atmosphere and that is a
9:29 huge environmental component to my crane
9:32 the other thing I want to just touch on
9:34 is that migraine is often still looked
9:37 at with
9:39 um stereotypes and looked at as you know
9:42 it’s it’s pain and it’s not interesting
9:44 and these individuals are just
9:45 complaining but we know that migraine is
9:48 truly a brain connection dysfunction
9:51 and and it’s
9:54 it’s really overall it causes an
9:57 increased sensitivity to what I say in
9:59 the slide stimuli and what that means is
10:02 there’s no there’s neuron dysfunction
10:04 the neurons are not talking to each
10:06 other properly
10:08 um and you and many migranters have
10:10 ongoing sensitivity to external stimulus
10:14 even outside of a migraine so what does
10:16 that mean it means that light bothers
10:19 you even if you’re not in the middle of
10:21 a migraine and that’s because a migraine
10:24 brain is awful at filtering out
10:27 information that is not important so I
10:30 don’t personally have migraine I’m able
10:32 to filter out noise light
10:35 um pressure changes because that my
10:37 brain is not interested in any of those
10:39 things but a migraine brain is and so
10:42 you’re always your brain is always on
10:43 high alert and you’re always perceiving
10:46 information or stimulus even when you’re
10:48 not in the midst of a migraine which I
10:50 think is important to know
10:52 the other piece is that migraine is
10:55 often present in individuals when
10:57 they’re younger from an early age and we
10:59 do think that this is more obvious in or
11:03 more present in individuals who have a
11:05 history of childhood trauma which we’re
11:07 not getting into but I will say that
11:09 there’s a really amazing book called the
11:11 body keeps score and it’s all about
11:13 trauma and how we manifest it through
11:16 chronic pain and that is completely a
11:19 different talk that we’re not going to
11:20 get into but the point is is that it’s
11:23 so
11:24 um there’s a lot of factors that play
11:26 into migraine and obviously what you
11:28 want to look for is a health care
11:30 provider that’s going to look at you
11:31 kind of holistically and as a person
11:33 because that’s really how I like to
11:36 tailor my medications and my treatment
11:38 plans so we’ll talk about that a little
11:40 bit later but I wanted to just set the
11:42 stage for that
11:44 one of the questions that was asked of
11:46 me is you know how you know migraine and
11:49 childhood and and when does migraine
11:51 first present itself and really migraine
11:53 is actually a major cause of uh
11:56 disability in young children we can even
11:58 see migraine in infants although not
12:00 frequently but you can and over to the
12:03 right you can see this kind of graph
12:05 here and on one axis is you know
12:08 prevalence how many or the frequency or
12:10 how many people have migraine and then
12:12 age on the long axis and then blue is
12:15 boys and and green or sorry pink is
12:18 girls and what you can see is that it’s
12:21 a pretty even climb to about mid
12:24 adolescence and then it drops down and
12:26 then obviously as hormones kick in uh
12:29 women kind of continue on with an
12:32 increase of migraine prevalence and boys
12:34 kind of settle down
12:37 prior to puberty like I said males and
12:39 females
12:41 sex-wise are are similar and what I will
12:44 say to uh which I forgot to to do my
12:46 little disclaimer is that I’m going to
12:48 be talking a lot about male and female
12:50 that’s based on sex and individuals when
12:53 I refer to them as females those are
12:55 individuals with a capacity for
12:57 pregnancy or individuals who produce
12:59 hormones endogenously so when I say male
13:02 and female throughout the talk that is
13:03 really what I mean
13:06 um little kids can have migraine the
13:08 criteria as a physician that I use is a
13:11 little bit differently there’s a Time
13:13 piece so they can have headache for two
13:15 hours instead of four they little people
13:18 get a lot of nausea and vomiting they
13:21 get a lot of
13:22 um warning prior to migraine even a
13:24 couple years earlier where you know if
13:27 you have a child who’s got lots of
13:28 motion sickness there are colicky baby
13:31 some kids who Sleepwalk or sleep talk or
13:34 kids who have a lot of stomach aches and
13:37 you can’t figure out why that can often
13:39 predate migraine by a couple years and I
13:42 often ask those questions in clinic when
13:44 I am seeing little people
13:46 um and then obviously you know
13:51 women start or females start to kind of
13:53 shoot off that curve and we’ll then
13:55 we’ll talk about that in the next slide
13:58 so migraine is actually three times more
14:01 common in like I said biological women
14:03 or or females with the capacity for
14:06 pregnancy than biological men there’s
14:08 this whole hormone mix which is exactly
14:10 why we’re having this talk it’s because
14:13 um we think as the this hpo axis is
14:17 actually an abbreviation for the
14:18 hypothalamus which is a part of the
14:20 brain the pituitary which is also a part
14:22 of the brain and the ovaries and
14:24 basically it’s just a kind of a highway
14:26 between the two of hormones and the
14:28 Brain tells the ovaries to start
14:31 producing the hormones because this
14:32 young female is getting ready to be able
14:35 to reproduce basically
14:38 um and so the average age of monarche
14:41 which is Menses or your first period is
14:43 about 12 and a half years old and often
14:46 that is the time when young women first
14:49 start having migraine
14:52 um you can also see migraine in young
14:55 women
14:56 um with folarchy which is breast Bud
14:58 development and so that’s usually around
15:00 the age of eight so when I say migraine
15:03 can happen at any age it’s absolutely
15:05 possible especially if there’s a strong
15:07 genetic or inherited family history but
15:10 we often see migraine and young women
15:12 out of anywhere from around eight to 12
15:16 13 14 depending on when their Muncie
15:18 starts so it’s really important to kind
15:21 of identify that and see that as a
15:24 physician I use that as a kind of a
15:26 gauge to see if I’m worried about any
15:28 other causes for migraines so if you’re
15:30 a kid who had people their period at 12
15:34 um and then has had migraines since it
15:36 sounds like that’s probably a hormonally
15:39 driven migraine disorder as as opposed
15:41 to something else that’s causing or
15:43 driving your your migraine you look for
15:46 um what we call secondary causes or
15:48 other causes of migraine like
15:52 um you know if you come to my clinic at
15:55 30 and you’re presenting with migraine
15:56 my job is to make sure that nothing else
15:58 bad is happening so tumors or Strokes or
16:01 anything else but if you say to me I’ve
16:03 had migraines since I was eight I’m a
16:05 little less worried and I’m a little bit
16:07 more confident in my diagnosis
16:09 foreign
16:13 so like I said estrogen and migraine is
16:16 a huge factor for many women but not all
16:18 women but we know that fluctuations in
16:22 sex hormones is really what’s driving
16:24 migraine for many people we don’t fully
16:27 understand how migraine Works
16:29 necessarily I um so it’s got a variety
16:33 of impacts in the brain
16:35 um you know how pain is perceived by a
16:38 person it can cause headache dizziness
16:40 nausea temperature changes in mood and
16:43 if you look at all of that constellation
16:44 of symptoms that’s really premenstrual
16:47 symptoms like before your period that is
16:49 a lot of for many women the symptoms
16:51 that they’re experiencing
16:53 estrogen is really a game of balance and
16:56 what I mean by that is it’s not all
16:57 estrogen is good and drives migraine and
17:00 a lack of estrogen is bad and that’s
17:02 also driving migraine estrogen can drive
17:05 migraine it can suppress migraine it can
17:08 kind of do a lot of things and I’ll talk
17:10 about it a little bit more but it’s
17:11 really about a hormonal soup and the
17:13 combination of the soup or the mixture
17:15 is really
17:17 um a key to predicting what kind of
17:20 symptoms you’re going to have and in
17:21 what stage of your life
17:23 so like I said here in the slide it kind
17:25 of has positive and negative effects in
17:27 the brain and we’re still understanding
17:29 obviously hormones and how it impacts
17:31 the body
17:35 so an interesting topic that I I
17:37 personally like talking about because I
17:39 see so many women in my office who have
17:41 menstrual migraine and the question I
17:44 was asked is why do so many women with
17:46 migraines see an increase in tax in a
17:48 tax migraine attacks with their
17:50 menstrual cycle
17:52 um and I really like this this slide so
17:54 the the pink part shaded we’re going to
17:57 ignore because that’s pregnancy and
17:58 we’re not talking about that
18:01 um so the far left and the far right or
18:03 my far left and my far right are the the
18:05 kind of two periods of time that I’m
18:08 going to be talking about so when we
18:10 talk about menstrual migraine we’re
18:12 really focused on the menstrual cycle
18:13 obviously
18:14 there are two types of migraine that
18:18 occur during during Menses or your
18:21 period one is called Pure menstrual
18:23 migraine and what that basically means
18:25 is that you only have migraine during
18:27 your period
18:29 that’s exceedingly rare I think in my
18:32 time in practice I have one pure
18:35 menstrual migraine patient that is it
18:37 some people that you talk to who are
18:39 headache Specialists do not think that
18:41 pure menstrual migraine even exists
18:44 um I think it exists but exceedingly
18:45 rare
18:46 um the rest of the population is really
18:48 built on what we call menstrually
18:50 Related migraine which means you have
18:52 worsening of your pure your migraines
18:55 during your period but also outside of
18:57 that time you can have migraine
19:00 um and what I was putting here below is
19:02 there was a study that was done out of
19:04 the Netherlands
19:06 and she had collected 692 patients and
19:09 she had surveyed them and only two
19:11 actually had pure menstrual migraine so
19:14 you can see that that’s exceedingly rare
19:15 and it’s not something that we typically
19:17 encounter in practice
19:19 menstrual migraine is a migraine that
19:23 typically does not have Aura and what
19:26 I’ll explain Aura is for those of you
19:28 who do not know that’s typically a
19:31 visual disturbance sometimes people
19:34 describe it as a white blob that comes
19:36 into their field of vision and kind of
19:39 slowly travels across some people get
19:41 static or snow some people get zigzag
19:44 lines or Kaleidoscope it can really be a
19:46 lot of things to to different people
19:48 some people will even get numbness or
19:50 tingling in their face around their
19:52 mouth and their arm and usually Aura
19:55 happens anywhere from five to sixty
19:58 minutes prior to your migraine or at the
20:01 same time that’s what we call an aura
20:04 the reason why
20:05 women who have menstrual migraine don’t
20:09 have Aura which I’ll talk about is
20:11 because we think menstrual migraine is
20:14 really a cause of estrogen loss so
20:17 estrogen if I can go back
20:21 estrogen is kind of this blue line so
20:23 right before you’re about to get your
20:25 period estrogen drops and that is what’s
20:29 driving mentally related migraine
20:32 we know that estrogen high estrogen can
20:36 cause Aura and we know that like I just
20:38 said menstruation or menstrually related
20:41 migraine is a lack of of estrogen so
20:43 these individuals get really really bad
20:46 bad migraines but they don’t get the
20:48 visual disturbance that they may get
20:50 outside of their period and the rule
20:53 with menstrual migraine is that it has
20:55 to happen at least two out of every
20:57 three cycles that a woman has
21:00 and the key for for menstrual migraine
21:03 is that typically the migraine starts to
21:06 build an intensity anywhere from two to
21:08 three days prior to your cycle starting
21:11 so many people say at the start of when
21:13 they’re getting their premenstrual
21:15 symptoms
21:17 um fatigue kind of just general malaise
21:19 irritable that kind of thing then the
21:22 migraine will actually start
21:24 and then can actually carry on into the
21:27 first couple days of their period and
21:30 then will should kind of Peter off
21:33 I will say that many women will get that
21:38 kind of a couple days before a couple
21:39 days during and then it’ll stop and then
21:42 they’ll actually get a flux of migraine
21:43 towards the end of their cycle we
21:46 actually do not think that that is
21:47 estrogen related we actually think that
21:49 is iron deficiency related because as
21:52 you can imagine you have blood now for x
21:55 amount of days and that headache is
21:57 actually an iron deficiency headache and
21:59 not necessarily A hormonally driven
22:01 headache
22:03 um and so typically I will say that
22:06 menstrual migraine pure menstrual or
22:08 menstrually related whichever one you
22:10 think you have is often very challenging
22:13 for a physician even a headache
22:15 specialist to treat and that’s because
22:19 ideally the best way to treat a
22:21 menstrual migraine is to treat the
22:23 hormones to kind of stabilize and not
22:26 cause this fluctuation in estrogen so if
22:29 an individual is severely debilitated by
22:31 menstrual migraines I often will do one
22:35 of a few things one will ask them to
22:37 talk to their gynecologist to see if an
22:39 oral contraceptive pill or progesterone
22:42 only pill or an IUD or some some way to
22:45 kind of smooth out the fluctuations that
22:47 a woman is getting during their period
22:50 the other thing is if you are a woman
22:52 who has very routine you know Clockwork
22:57 kind of menstruation and migraine then I
23:00 can do something and I’m I said I wasn’t
23:02 going to talk about drugs and I’m not
23:04 going to talk about drugs
23:05 but we can do something called a mini
23:07 prophylaxis where I actually treat you
23:09 during the course of your period with
23:12 certain medications
23:14 um and sometimes I even use supplements
23:16 like magnesium which has great evidence
23:18 and headache to try and get ahead and
23:21 try and help you out during that period
23:22 of time that’s so debilitating for you
23:25 um so that’s kind of the the gist of
23:28 menstrual migraine
23:29 in a nutshell
23:32 the next topic which I think is the
23:35 topic that is maybe most interesting to
23:37 many people maybe that’s why they joined
23:39 this webinar is really perimenopause and
23:41 menopause and I find that this is also
23:43 an exceedingly challenging
23:46 um migraine to treat
23:48 um and you know any perimenopausal woman
23:51 that comes into my office always first
23:53 question asked me is is my headache
23:55 going to get is my migraine going to get
23:57 worse is it going to be over when my
23:59 medical like when I’m out of menopause
24:02 um and I’ll talk about that because
24:04 there’s no real easy answer so now we’re
24:07 kind of on to the far you know right of
24:11 the screen in terms of all of a sudden
24:14 your your estrogen is you know dipping
24:16 down and then you get all these you can
24:18 see these kind of squiggly lines where
24:19 it’s just your estrogen is all over the
24:21 place
24:22 and you also have a hormone called
24:24 progesterone which is also kind of
24:26 petering off and eventually you go down
24:28 to nothing and that is that is menopause
24:31 foreign
24:33 so menopause for those of you who do not
24:37 know is basically divided into three
24:39 stages so pre-menopause in a nutshell is
24:42 your reproductive years those are the
24:44 years that you are supposed to be
24:47 reproducing so you know there’s very
24:50 little fluctuation in your period it’s
24:52 supposed to be very little fluctuation
24:54 in your period around that time so your
24:56 cycle doesn’t fear too much more than a
24:59 week you’ve had a period within the last
25:02 12 months or are you sorry you haven’t
25:03 missed more than one period in the last
25:05 12 months and then the time that most
25:09 people are interested in is this
25:11 perimenopausal period
25:13 so typically the age that perimenopause
25:16 starts is anywhere from 45 to 55 years
25:19 old and I typically say you know ask
25:23 your your mother or your grandmother or
25:26 your sister who’s older what age they
25:28 went through menopause and that’s
25:30 usually what age you go through
25:31 menopause but obviously that can
25:34 fluctuate the perimenopause stage can
25:37 last quite a long time and you kind of
25:39 have two phases to perimenopause you
25:42 have an early and a late phase and so
25:45 basically the the gist of perimenopause
25:48 is that the cycle can vary greater than
25:51 a week your period can be anywhere from
25:54 2 to 12 months in in in in
25:57 space and you’ve missed more than two
26:00 periods in the last year that’s kind of
26:03 the perimenopausal stage
26:06 and then the last but not least is
26:08 menopause and the overall gist of this
26:11 period or this time in your life is that
26:13 there’s no menstrual periods for greater
26:16 than a year
26:17 um and then I’m getting back to that
26:18 kind of hormonal soup that we talked
26:20 about whereas the mixture of estrogen
26:23 and progesterone is fluctuating but
26:25 basically at the time you hit menopause
26:27 you should basically have low levels of
26:30 estrogen there’s less of this kind of
26:32 fluctuation that we see in the curve in
26:34 the curves that I showed you before and
26:36 your progesterone is basically down to
26:38 nothing at that point that’s the
26:40 menopausal or post-menopausal phase
26:46 so the question is does migraine
26:48 typically get better or worse during the
26:50 later years of a woman’s life
26:52 um and I really like this question but
26:54 it’s not an easy question it’s not a yes
26:55 or no answer so
26:58 there was a really great study done by
27:00 the American migraine prevalence and
27:03 prevention study which is kind of a
27:04 mouthful but basically they looked at a
27:07 bunch of women who already have
27:09 migraines so I’ll preface that this
27:10 study was done in women who’ve already
27:13 gone into the perimenopausal menopausal
27:16 period with migraine
27:18 um and so there’s often just to be
27:22 honest there’s it’s often worse it’s
27:24 often worse during the perimenopausal
27:26 period
27:28 um and that those years when you’re
27:29 transitioning into menopause are not
27:31 always amazing years I will have to say
27:34 but I will say that is for a woman who
27:36 has menopause or has migraine that is
27:39 really linked
27:40 um to hormones they’re kind of the
27:42 classic migraine that started at their
27:44 you know
27:45 around their period it’s kind of been
27:47 persistent throughout their lifetime
27:49 they’ve got worsening during their
27:51 period that’s probably nine times out of
27:54 ten their migraine is not going to be
27:56 great during the perimenopausal period
27:59 the other really interesting piece that
28:02 I find is the type of menopause is
28:04 really important to note so migraines
28:07 are less or 40 percent less often or
28:10 present after a natural menopause so
28:12 what does natural menopause mean it
28:15 means exactly what you what you think so
28:17 spontaneous menopause menopause that is
28:20 induced is not a natural menopause
28:23 surgically induced menopause is not
28:25 obviously a natural menopause and so
28:28 that can often be associated with severe
28:31 intensification or worsening of migraine
28:34 if you are um unfortunately in those
28:36 situations where you have a not natural
28:39 menopause
28:41 um so whenever a woman’s ovaries are
28:44 removed and you’re not and we’re not
28:45 adding estrogen back into the the
28:48 woman’s system that’s usually when an
28:51 individual will have more frequent and
28:53 more disabling migraines or headaches
28:56 it’s around that time
28:58 the star study that we looked at or that
29:01 they looked at all these women I think
29:03 there was a for 20 000 women that they
29:05 looked at preventative medications were
29:08 used the most in the late perimenopause
29:10 menopausal stage so why does that even
29:13 matter is because as a headache
29:16 physician as a neurologist I typically
29:18 choose preventative medications which
29:20 means a daily medication in individuals
29:23 who have more than 15 days a month of
29:25 headache so this basically this line is
29:28 telling me that
29:30 headache was extremely more frequent in
29:33 the perimenopausal stage in the late
29:36 stage in women and so kind of the short
29:39 answer is that yes perimenopause is not
29:42 a great time for migraine but we hope
29:44 that in the end uh throughout menopause
29:47 that things get better for many women
29:50 I will add and I think I mentioned this
29:53 before perimenopause and migraine is you
29:56 know worse in women who have a history
29:58 of menstrually related migraine whether
30:00 that’s for migraine around mensy so
30:03 whether that’s your you know the rare
30:04 bird that is the pure menstrual migraine
30:07 or menstrually related migraine
30:09 um I I kind of highlighted this excerpt
30:12 from the study because I thought it was
30:14 really it was really helpful and I want
30:16 to talk about it a little bit more so
30:18 during menopause migraine prevalence or
30:21 the you know the presentation of
30:23 migraine decreases overall so that’s I
30:25 think a bright light for many people
30:28 but
30:29 um like anything it really depends on
30:32 what you look like going into menopause
30:33 and perimenopause so for those who
30:36 didn’t have high frequency migraine or
30:39 headaches going into menopause many
30:41 women
30:42 lost their migraine characteristics so
30:44 they weren’t you know hiding in a dark
30:46 quiet room light wasn’t constantly
30:49 irritating them and bothering them they
30:51 they may have had you know what we call
30:53 tension type headache it’s you know it’s
30:55 mild it’s annoying you don’t have to go
30:58 to the emergency department
31:00 um you can you can handle using you know
31:02 Advil or whatever it’s it’s a manageable
31:04 headache
31:06 um and so that is what we see most often
31:09 in women with low frequency migraine or
31:11 low frequency headache
31:13 some women can have a higher frequency
31:15 of headaches with a decrease in migraine
31:18 and I find that those are individuals
31:19 who went into the perimenopausal or
31:22 menopausal stage with lots of migraine I
31:25 definitely have women
31:27 who have like two three migraines in a
31:31 week and so those individuals when they
31:34 enter into perimenopause May or when the
31:37 sorry when they enter into menopause may
31:39 have
31:41 um less migraine still a lot of headache
31:43 I’m not saying it’s going to be perfect
31:45 they still may have a lot of headache
31:46 but they’re really debilitating
31:48 migraines are hopefully a lot less
31:50 frequent
31:51 um and that is in the menopausal reach
31:54 the menopausal range so the moral of the
31:57 story is I can’t with with confidence
32:00 predict
32:01 um you know what a woman is going to
32:03 look like once they reach menopause and
32:04 I’m pretty upfront with my
32:07 perimenopausal and menopausal patients
32:09 each individual as I’m sure you all know
32:11 or are extremely unique and so I like to
32:15 provide some hope but I’d like to be
32:17 realistic and and just we have to kind
32:21 of watch and wait and see what happens
32:22 to be honest
32:27 so the other question that I was asked
32:30 is is it common for menopause or
32:32 perimenopause to trigger new onset
32:35 migraine
32:37 that’s also a very good not an easy
32:40 question because migraine can happen
32:41 literally at any age
32:44 um there was actually a study that was
32:45 put out that I kind of quoted here
32:47 there’s kind of actually two peaks to
32:49 migraine so you know migraine is
32:52 typically seen in um the Adolescent
32:54 years like I talked about but there’s
32:55 like a like a cluster of women who
32:58 present with migraine around the 18 to
33:00 44 year old range kind of dies out a
33:03 little bit and then can kind of pick up
33:04 so actually there’s a there’s not a
33:07 small
33:08 a group of or population of individuals
33:12 who start to actually present with
33:13 migraine in their 60s and so those
33:16 individuals I will preface and say that
33:19 they’re probably not hormonally linked I
33:21 don’t think
33:23 um but it’s absolutely not outside of
33:26 the realm of normal to to have your
33:28 first migraine at the age of 60.
33:30 migraine is obviously more active prior
33:33 to the age of 50.
33:36 perimenopause
33:38 increases other condition it you know
33:40 increases other medical we call them
33:42 comorbid other things other medical
33:44 health issues often arise around the
33:47 perimenopausal time so if you or someone
33:50 who came into my office and said you
33:53 know all my life I’ve had you know maybe
33:56 two headaches a week one headache a week
33:59 and then all of a sudden now that I’m in
34:01 the perimenopausal stage I am just like
34:05 flooded with migraine I am debilitated I
34:07 cannot function but I was never a person
34:10 who had menstrually related migraines
34:12 like migraines did not you know become
34:15 more frequent around my period hormones
34:17 were never an issue for me and what I
34:19 would say is during the perimenopausal
34:21 reach at the time often mood is impacted
34:24 so anxiety and depression is a little
34:26 bit worser worse around perimenopause
34:28 sleep you know you’ve got all these
34:30 night sweats and Hawk lashes you can’t
34:32 sleep so you don’t get deep restorative
34:34 sleep and so all of that can contribute
34:37 to worsening of migraine during that
34:39 time so you could have been grumbling
34:41 along with a few headaches and then have
34:44 a surge of headache around your your
34:46 perimenopausal period of time
34:50 as a physician if you come to my office
34:53 and you have your first presentation of
34:55 migraine after the age of 50 it is my
34:59 job to make sure that nothing else is
35:01 happening so I talked really quickly
35:04 about secondary headaches or what that
35:06 means is other causes of headaches so
35:08 whether that is
35:10 um you know a tumor or a stroke or you
35:13 know I make sure that there’s no clots
35:14 in your blood vessels in your brain and
35:16 my job is to make sure that there’s not
35:18 another medical condition that should be
35:20 treated before we just rest and say this
35:23 is migraine let’s move on to the
35:25 treatment phase if that makes sense so I
35:27 would say you know if you’re over 50 and
35:30 you’ve been grumbling along through your
35:31 life with just one or two headaches that
35:33 seem very manageable and then all of a
35:35 sudden in your 50s you are having the
35:37 worst headaches of your life and you are
35:39 debilitated I wouldn’t be so quick to
35:42 say man it’s nothing I would obviously
35:44 present to your health care provider and
35:46 talk to them and and kind of make sure
35:49 that everything is okay and there’s
35:51 nothing else being missed
35:55 what is hormone replacement and who is
35:58 it best suited for and is it safe the
36:01 short answer is I don’t prescribe HRT or
36:04 hormone replacement therapy I can give
36:06 you my opinion on HRT from a neurologist
36:11 perspective and a headache medicine
36:14 perspective and my thoughts about that
36:16 but obviously the the risks and the
36:19 benefits of HRT are really something
36:20 that needs to be discussed with your
36:23 gynecologist or your primary care
36:25 provider so that’s my my little
36:26 disclaimer
36:28 um for those of you who don’t know what
36:31 hormone replacement therapy is it’s
36:32 really the goal is to supplement or add
36:35 back hormones that are lost during the
36:37 menopausal transition the perimenopausal
36:39 period it’s trying to create a balanced
36:44 hormonal soup sort of so to speak so
36:46 like I said your hormones are all over
36:49 the place they’re fluctuating day to day
36:51 week to week and the goal of HRT is just
36:54 to keep everything as smooth as possible
36:58 the the red is you know why don’t we
37:01 want to use hormone replacement therapy
37:04 and so we don’t use hormone replacement
37:07 therapy and anyone who has a history of
37:09 breast cancer and anyone who has put CHD
37:13 which is
37:14 um a heart disease basically anyone
37:17 who’s ever had a stroke in the in the
37:20 blood vessels in the legs or in the
37:22 lungs or in the brain anyone who has any
37:25 liver issues we don’t use HRT and anyone
37:29 who’s had vaginal bleeding that can’t be
37:31 explained would be like a hard no
37:34 when can you use HRT it’s actually just
37:38 a very curated group of it of women
37:41 really so I personally would probably
37:44 not consider hormone replacement therapy
37:47 for anyone who’s not you know
37:49 exceptionally healthy and what I mean is
37:51 that there’s no high blood pressure
37:53 there’s no diabetes there’s nothing you
37:55 are not on a medication you’re not even
37:57 maybe you’re taking supplements but
37:59 otherwise you are the pillar of Health
38:01 the max you can use HRT is about five
38:05 years and you can absolutely hard know
38:08 be taking it beyond the age of 60. so
38:10 you can see that it’s a very curated
38:13 group of individuals that would actually
38:15 meet the criteria for hormone
38:17 replacement therapy
38:21 um so what does it mean for migraine
38:23 which is why you’re all here so hormone
38:26 replacement therapy this is kind of a
38:28 busy slide but I wanted to make sure we
38:30 got it all in so it has a kind of a
38:33 variable impact on migraine so what does
38:36 that mean it may actually worsen
38:39 um migraine in women who already have
38:41 migraine or it actually could has been
38:44 known to induce migraine in women
38:46 without a history of migraine and that’s
38:48 because estrogen like we know isn’t as
38:52 easy as estrogen withdrawal causes
38:55 migraine or estrogen increase causes
38:57 migraine it’s this net effect that I was
38:59 talking about so too much
39:01 um estrogen can actually cause Migraine
39:04 with that visual disturbance that I was
39:06 talking about
39:08 um and so worsening of migraine in
39:10 menopause may be a predictor of you not
39:14 doing well on my on on hormone
39:17 replacement therapy so I’ll say that
39:19 again if your migrain grades get worse
39:21 during the perimenopausal region
39:24 the perimenopausal period of your life
39:27 you may not be the best person to be on
39:31 hormone replacement therapy and in fact
39:33 there’s a high likelihood that you would
39:35 not
39:35 um do well on it from a migraine
39:37 perspective
39:39 um there are some reasons why HRT
39:43 therapy could be beneficial so some
39:46 studies suggest that the non-oral roots
39:49 of estrogen could be helpful like the
39:51 patch or the gels and that’s because we
39:54 think that there’s maybe a steady stream
39:56 of estrogen being delivered and it’s
39:59 kind of helping to control the
40:00 fluctuations that you’re getting during
40:02 during
40:03 menopause but again that’s you know very
40:07 person dependent patient dependent
40:11 from a neurologist’s point of view from
40:14 a stroke perspective
40:16 we think that there is an increased risk
40:19 of stroke in individuals with with
40:20 hormone replacement therapy even if you
40:22 didn’t have a prior history of stroke in
40:24 the past and I’m happy to talk about
40:26 that more in detail but I personally do
40:30 not
40:31 um
40:32 think that HRT therapy is something to
40:36 be taken lightly and you’d really have
40:37 to have a really engaged conversation
40:39 between if you have a neurologist or a
40:42 primary care provider and your
40:43 gynecologist about is that the right
40:46 treatment for you
40:52 okay and so the other thing is you know
40:54 seeking Healthcare practitioners and
40:56 advocacy I think first and foremost
41:01 um you know
41:02 being part of these webinars and forming
41:04 yourself is like it’s such a huge piece
41:06 to that you know how do you
41:09 um advocate for yourself ideally you
41:11 want to find someone that’s you know
41:12 willing to listen to you and that can
41:14 often be really challenging uh like I
41:17 said before the other pieces that I’ve
41:19 seen countless numbers of women who say
41:21 I get a migraine or a headache one or
41:24 two times a week that’s normal and the
41:26 first thing I say is that is absolutely
41:28 not normal I do not get a headache one
41:30 or two times a week I don’t even get a
41:32 headache once a week so I think it being
41:35 comfortable and advocating for yourself
41:37 talking to your primary care provider
41:39 about migraine or headaches in general
41:42 and just making sure that everything
41:45 um is okay that the your health care
41:47 professional is not worried about your
41:49 headaches um and that’s it’s not
41:50 something to be overlooked because it
41:52 can absolutely be treated
41:53 the other thing is you know if you’re
41:55 for whatever reason don’t think that
41:58 you’re getting the answers that you want
41:59 to get from your primary care provider
42:01 there are neurologists with their all
42:03 neurologists are trained in and headache
42:06 um at one point in our residency
42:08 training and then you can ask for a
42:10 migraine specialist if there’s one in
42:12 your area
42:14 um and then you can deep go deeper and
42:17 find a migraine specialist who
42:18 specializes in women’s issues and
42:20 headaches like myself which is not as as
42:22 easily read as
42:25 um as available as what um we’d like it
42:29 to be but obviously you know you can
42:32 kind of ask around talk to people and at
42:35 least try and seek out
42:38 um and keep looking for someone that’s
42:39 willing to answer your questions and and
42:41 provide help I think would be the best
42:43 thing I also think that it’s really
42:45 important to talk to other people
42:49 um because you’d be surprised at how
42:51 many individuals neighbors friends
42:53 co-workers usually have migraine and
42:55 they’re often a wealth of of knowledge
42:57 and information
42:59 the question is you know what type of
43:01 practitioner is most suitable for
43:02 managing hormonal migraine that’s not
43:04 really an easy an easy question I think
43:07 like I said you just want someone who’s
43:10 willing to listen and if they don’t know
43:12 the answer that they’re willing to find
43:13 the answer for you and obviously like I
43:16 said
43:17 um you know
43:19 going and informing yourself going to
43:22 migraine Canada going to other resources
43:24 I’ve named a couple here the American
43:26 migraine Foundation are all very helpful
43:28 to provide
43:29 um some resources literature things for
43:31 you to read resources for you to utilize
43:35 the question of you know how do you
43:38 involve multiple providers to work
43:41 together for you I have a lot of
43:43 patients that say you know I see a
43:45 gynecologist can you copy your notes to
43:47 my gynecologist absolutely then I don’t
43:50 make more work for the family family
43:52 physician I just go directly to the
43:55 gynecologist you just really need to
43:57 communicate and kind of talk about what
44:00 your expectations are or what your goals
44:02 are don’t ever be afraid to ask
44:06 um in terms of treatment we’re not going
44:08 to get into it obviously but there’s a
44:10 lot of options for treatment right now
44:12 it is like the best time for me to be a
44:15 headache specialist because I’ve got all
44:17 these
44:18 um well I have all these drugs and
44:20 options to use in in my migraine
44:23 patients and whether that’s oral
44:25 injectables like once monthly once every
44:28 four months these are this is the time
44:30 to really talk to your primary care
44:33 provider your neurologist your headache
44:35 specialist about medications and options
44:37 I I think that would be the best thing
44:40 and I the last point I want to say is
44:42 you know yourself you know what’s normal
44:44 and you know what’s not normal for you
44:47 um and so like I mentioned before many
44:49 patients don’t talk to their primary
44:51 care provider
44:52 on the flip side you know I’m trying in
44:55 the background giving talks to other you
44:57 know family doctors and people to say
44:59 listen migraine is just as
45:03 prevalent or or present as high blood
45:06 pressure and diabetes and we’ve got to
45:08 start screening uh individuals for
45:10 migraine more so there’s kind of
45:12 advocacy that needs to be done in the
45:14 back end and there’s also kind of more
45:16 advocacy that I’m trying to encourage my
45:19 patients to tell friends tell loved ones
45:21 that there’s really an option and a
45:23 treatment path for many people
45:27 um why is advocacy so important to
45:30 improve an advanced treatment in
45:32 migraine
45:33 like I said before there’s just so much
45:36 stigma around migraine still and it’s
45:39 it’s very sad to be honest I think that
45:41 it’s still like I said under reported
45:45 um you know it’s not a particularly like
45:47 attractive and sexy disease
45:49 um it doesn’t get a lot of donor money
45:51 it doesn’t get a lot of
45:53 um you know advertising and that’s why
45:56 migraine Canada and you know other other
45:58 programs are so important to kind of get
46:01 the word out and make people feel a lot
46:02 less isolated because I do see that a
46:05 lot or hear that a lot that um women
46:07 with migraine or people with migraine
46:09 feel isolated and they feel like they’re
46:11 not understood and that’s why advocating
46:13 for yourself getting out there talking
46:15 about migrating with friends and loved
46:17 ones and co-workers is really important
46:20 on my end you know I’m trying to you
46:24 know facilitate or try and encourage
46:26 more knowledge around migraine so
46:29 whether that’s I’m speaking to Family
46:32 Physicians or you know gynecologists and
46:35 talking about menstrual related migraine
46:37 or a migraine during pregnancy
46:40 um that’s super important and trying to
46:43 work on that in the back end the other
46:45 piece is we just need more headache
46:46 specialists
46:48 they train we train one well two
46:50 headache specialists in the country each
46:53 year that’s not very many of us and
46:55 we’re kind of all kind of densely
46:56 populated in the Toronto area to be
46:59 honest most of us trained at Women’s
47:00 College which is a headache Center and
47:02 we kind of all kind of scattered you
47:04 know around there but we need more
47:07 headache trained Physicians and so we’re
47:09 trying to work on that but that’s going
47:11 to be a slow process
47:13 um and then the last piece is we just
47:15 need to
47:16 keep going with new advances in the
47:18 field like I said there’s a lot of new
47:20 medications that we’ve been waiting and
47:23 hoping and wishing for that have finally
47:24 come across the border
47:26 and we just need you know more
47:28 advancement more research to be
47:30 completed and you know more more options
47:33 for people we have more options though
47:36 for migraine than we ever did
47:38 um in the last 10 years so it is an
47:40 exciting time not to have migraine but
47:43 it’s an exciting time to treat migraine
47:45 because I feel like there’s so many
47:47 options that I can customize for for
47:49 patients
47:51 um and with that I thank you