The Female Life Cycle and Migraine

0:04 welcome everybody it’s just it’s a
0:05 great crowd i understand tonight so
0:07 thanks for attending i got into the
0:09 headache field just a little bit of
0:10 background
0:11 back in 1991 um and it was a memorable
0:14 year because it was the first year that
0:16 one of the triptans was launched it was
0:18 sumatra 10 in 1991
0:20 so it goes back a long long way and back
0:23 in 1991 it was
0:25 there wasn’t migraine canada it was the
0:26 migraine foundation and we used to have
0:29 migraine awareness week and
0:33 before sumatriptan the only thing we had
0:35 even when i was in residency
0:36 were the ergotamines furanol and tylenol
0:40 with codeine if you can imagine
0:41 and in terms of preventatives we had
0:43 amitriptyline
0:45 propranolol um
0:46 [Music]
0:48 i think sandal migraine and sensor which
0:51 you can’t even get anymore
0:53 so we’ve really come a long way there
0:55 was a bit of a slump in the action for
0:57 about 10 years
0:59 and then botox came back with the
1:01 triptans from 1991 through to 2000
1:06 and then we there was a bit of a lull
1:08 again but then now with these new
1:11 monoclonal antibodies the cgrp
1:13 medications as i’m sure you’ve all heard
1:15 about
1:15 there’s been a real flurry of activity
1:17 so there’s a lot happening in the
1:19 migraine world
1:20 having said that unfortunately
1:23 the data that i’m going to be presenting
1:25 to you in
1:27 migraine in the female life cycle a lot
1:29 of its old data
1:31 and some of it goes back to 1970 with
1:34 the original research being done
1:36 by somebody called summerville where he
1:38 basically made the discovery that
1:40 migraine associated with menses was
1:43 because of a drop in estrogen levels
1:46 and it’s sad to say that we haven’t
1:47 really come that much further
1:49 in terms of some of the studies we do
1:52 have a few studies that looked at
1:53 treatment of menstrual migraine
1:55 but it’s very interesting that that
1:58 hasn’t really
1:58 propelled forward that much so um
2:02 with all that um what we’re going to do
2:04 this evening
2:05 is go through the life cycle of migraine
2:08 you’ll see that migraine is with the
2:10 female patient
2:12 right from the time they start puberty
2:14 right through
2:16 menstrual cycles through pregnancy
2:18 associated with hormones and hormone
2:21 replacement therapy
2:22 pregnancy breastfeeding right into
2:25 menopause and sometimes after menopause
2:27 so we’ll walk through this cycle tonight
2:29 together
2:30 and um if you have questions you can put
2:32 them on the chat
2:33 and we’ll save them till the end and
2:35 deal with them then you’ll see that i’ve
2:37 introduced these are my disclosures by
2:38 the way but they really don’t have a lot
2:40 of relevance here
2:42 and what we’ll do this evening is we’ll
2:44 talk about the effects of hormones on
2:46 migraine throughout the life cycle
2:48 we’ll talk about some of the treatment
2:49 strategies of menstrual migraine in
2:51 particular
2:52 and discuss the effects of the oral
2:54 contraceptive on migraine
2:56 and migraine and aura in particular and
2:58 the effect of stroke risk
3:00 and then touch a little bit on pregnancy
3:03 on migraine and breastfeeding and also
3:05 review some of the treatment options
3:06 that we have available
3:09 so just a little bit of background in
3:11 terms of what migraine is as far as the
3:13 international headache criteria are
3:15 concerned
3:16 there is a large large series of
3:18 headache diagnostic classifications
3:20 over 200 of them that are classified in
3:23 the international headache criteria so
3:25 migraine without aura which is by far
3:27 the most common that we have
3:30 these are the criteria that are
3:32 suggested to make the diagnosis
3:34 and we need to have at least five
3:35 attacks um the attacks last anywhere
3:38 from four to 72 hours
3:40 and they have to have more than two of
3:42 the following so they have to be
3:43 one-sided
3:44 pulsatile and quality moderate or severe
3:47 pain aggravated by
3:48 activity during the headache we like to
3:51 see more than one of the following
3:52 including nausea or vomiting sensitivity
3:54 to light which is photophobia
3:57 and sound phonophobia now
4:00 we also need to rule out the fact that
4:02 this might be related to an underlying
4:03 disorder either a tumor or infection or
4:06 something else that
4:07 makes it clear that it’s not migraine
4:09 related i’m going to suggest to you that
4:11 these are suggested criteria we clearly
4:14 see patients who have migraine that
4:16 don’t meet all of these criteria
4:18 but based on the clinical history they
4:20 certainly do fit the
4:21 the pattern of migraine and then we have
4:23 migraine with aura which is far less
4:25 common
4:26 and you may have both within the same
4:28 patient you may have a patient who has
4:30 migraine without or their whole life
4:32 and then lo and behold when they become
4:34 perimenopausal or when they become
4:35 pregnant they start to develop auras
4:38 and auras really are a set of symptoms
4:41 that are neurological
4:42 and they could be anything from visual
4:45 to sensory meaning numbness and tingling
4:48 or they could be motor meaning paralysis
4:50 they could involve
4:51 speech and language but typically they
4:54 occur
4:54 before the headache comes on they could
4:56 last 5 minutes 20 minutes or even an
4:59 hour or more
5:00 and then the headache follows this and
5:02 again that’s the typical pattern
5:04 there are some that evolve much much
5:06 slower that are some that are actually
5:08 occurred during the headache themselves
5:10 but less than 15 percent of patients who
5:12 have migraine have migraine with aura
5:14 so much less common
5:17 okay so let’s get to the prevalence in
5:19 women
5:20 as you see the bars here the orange bars
5:22 represent females the green bars
5:24 represent males
5:26 across you see the representative ages
5:28 of patients
5:30 and as females start puberty around the
5:32 age of 14 to 15
5:34 we start to take off in terms of the
5:36 prevalence of migraine for that
5:38 year they really peak between the ages
5:40 of 25
5:41 down to about 45 to 50 and as women go
5:45 through menopause
5:46 the migraine prevalence reduces so for
5:49 every one male
5:50 you have two or three females that have
5:52 migraine
5:54 if we were to look at this bar starting
5:56 at the age of
5:57 five going up until menarche which is
6:00 when we start our menses
6:02 that bar would shift because the
6:04 prevalence is higher
6:06 in little boys than it is in little
6:07 girls pre-puberty
6:10 so they tend to have a higher prevalence
6:12 before we start our menses and then
6:13 after menses
6:15 they take off in the female population
6:19 ovarian hormones have a lot to do with
6:21 this um eighty percent of female
6:23 migraners have their first migraine
6:25 between the ages of 10 and 39 years
6:29 i really i suggested that there were
6:30 studies in the 70s done by somebody
6:32 called
6:32 somerville and he identified there was a
6:35 drop in estrogen
6:36 just before the menses occurs and that
6:38 seemed to be the culprit for triggering
6:40 migraine
6:41 we know that estrogen increases
6:43 serotonin synthesis and you’ve heard
6:45 about serotonin
6:46 in relation to the tryptans things like
6:48 imatrex and zomig
6:50 and max salt those medications that you
6:52 take when you get a migraine
6:54 affects serotonin we also know that
6:56 estrogen decreases serotonin degradation
6:59 and estrogen also affects things called
7:01 prostaglandins which
7:03 are things that cause inflammatory
7:06 changes
7:07 when a migraine occurs magnesium which
7:10 we know has a protective effect
7:12 on migraine and nitrous oxide which i’m
7:14 going to suggest to you stay tuned
7:16 because right now research is happening
7:18 with regards to nitrous oxide
7:20 and its protective effect on migraine in
7:23 terms of nitrous oxide medicate related
7:25 medications
7:26 so it’s going to be coming up in the
7:28 near future
7:30 so i presented some cases here because i
7:32 think that it
7:33 it may be an easier way to relate to
7:35 some of the changes related to migraine
7:37 and you may be able to relate to some of
7:39 the details in the cases so we’ll walk
7:42 through a couple of cases together
7:44 so this is a 32 year old woman her
7:46 migraines began at the age of 12. her
7:48 menstrual cycles began at around the
7:50 same time within about six months
7:52 of her migraines beginning initially
7:54 they were about three times a month
7:56 but the headaches that occurred during
7:57 her menstrual cycle were typically much
7:59 more severe they lasted longer
8:02 and she would get occasional visual
8:03 symptoms associated with her migraines
8:05 so she would describe
8:07 seeing a kaleidoscope in her vision
8:09 sometimes she would look
8:10 and it would feel like sometimes in a
8:12 hot summer day when you see the heat
8:13 waves rising off the pavement
8:15 she would sometimes see some flashes of
8:17 light occurring with these
8:19 these headaches that occurred with her
8:21 menstrual cycle the only relevance to
8:23 her history was that her mother had a
8:24 background history of migraines but she
8:26 was
8:26 otherwise well no real medical problems
8:30 so what’s the diagnosis what are the
8:32 things that go through our mind when we
8:33 see a patient who presents with this we
8:35 think about migraine without aura
8:38 we think about menstrual related
8:40 migraine
8:41 and then true menstrual migraine those
8:43 are the all
8:44 all the diagnostic considerations that
8:46 we have
8:48 so what’s menstrual related migraine
8:50 that’s by far the most common
8:52 and that’s typical headache that occurs
8:54 anywhere from
8:55 day minus two to day plus three and by
8:59 that i mean if you look at your
9:00 menstrual cycle day zero is the day that
9:03 you start menstruation
9:04 day minus two is two days before then
9:07 and day plus three
9:09 is three days after you’ve started your
9:11 menses
9:12 so the timing of treatment really
9:14 relates to when your headache begins
9:16 not when you’re meant not when your
9:18 menses begins
9:19 and and that’ll become clear to you in a
9:21 moment when i start to talk about
9:22 treatment
9:24 premenstrual syndrome headache onset day
9:27 minus seven to day zero with the
9:30 headaches associated with pms so
9:32 different than menstrual related
9:34 migraine
9:35 and the headache usually resolves as
9:36 soon as they start their menses
9:38 so that’s how we distinguish the two
9:40 again menstrual related migraine
9:43 there’s about a five day period that’s
9:45 around the menstrual cycle but it
9:46 continues into the menstrual cycle
9:48 even after menses starts a pms-related
9:52 headache
9:52 tends to stop with the onset of menses
9:55 and as you are well aware
9:56 has a whole series of other symptoms
9:58 associated with pms
10:02 menstrual migraine is a bit unique in
10:05 terms
10:06 of other migraines that you may get
10:07 during other times of the month
10:10 it’s perceived by both physicians and by
10:13 patients as being much more severe
10:15 longer duration refractory to treatment
10:18 it doesn’t usually respond as well to
10:20 the usual medications so you could take
10:22 a nematrix or max alter naproxen or a
10:25 leave
10:25 for your other migraines during the
10:27 month but when you have a menstrual
10:29 migraine
10:30 it just doesn’t seem to work it doesn’t
10:32 last as long
10:33 it may take the edge off the headache
10:34 but it doesn’t eliminate it completely
10:37 there are no studies to back this up
10:39 this is just purely anecdotal experience
10:43 so if you look at migraine attacks in
10:45 relation to the menstrual cycle i spoke
10:47 to you about menstrual related migraine
10:49 and menstrual related migraine
10:51 takes up about 50 percent of migraine
10:54 attacks related to the menstrual cycle
10:55 so by far the most common one
10:58 then you have migraine attacks that
11:00 aren’t really associated with menses
11:01 that represent 40
11:04 there’s a small percentage of patients
11:06 who have
11:07 pure menstrual migraine so these are
11:10 women who don’t have migraines at any
11:12 other time of the month they’re not
11:14 triggered by
11:14 alcohol or weather or anything else they
11:18 strictly have
11:19 pure menstrual migraine very uncommon
11:22 we don’t know if physiologically they
11:24 are any different
11:25 they do respond the same as menstrual
11:27 related migraine but they’re still very
11:29 difficult to treat
11:31 and still don’t respond as well to
11:33 medication as menstrual related
11:34 migraines so the question has always
11:36 been
11:36 are they a different type of menstrual
11:39 migraine are they physiologically
11:40 different we really don’t
11:42 know and as i said there’s a real lack
11:44 of
11:46 studies that are being done over the
11:48 last 10 or 20 years
11:49 in this area so we really don’t know
11:52 very much about it
11:54 so menstrual related migraine occurs in
11:56 about 60
11:58 of women who have migraine so it’s quite
12:00 common it tends to occur day minus two
12:02 today plus three
12:04 it can vary plus or minus one or two
12:06 days
12:07 um estrogen withdrawal headache it can
12:10 occur what if patients are taking
12:12 exogenous estrogen hormone replacement
12:15 therapy
12:15 oral contraceptives if they’re taking
12:18 those every day
12:19 and then they stop it just like the
12:21 birth control pill
12:22 and you can get that estrogen withdrawal
12:24 headache so you’re on oral
12:25 contraceptives you stop it for your days
12:27 off
12:28 that’s when your headache may occur
12:30 menstrual related migraines tend to
12:32 produce
12:32 more disability than regular migraines
12:35 do they tend to be more
12:36 severe and as i mentioned less
12:38 responsive to treatment than
12:39 non-menstrual migraine
12:41 and they lead to higher medication
12:43 overuse and more quantification of
12:45 headache
12:46 and higher disability rates so how do we
12:49 manage this particular patient
12:51 she needs acute therapy so we would try
12:55 the usual therapies we would try
12:57 anti-inflammatories we would try
12:58 tryptans the usual things that we would
13:00 try
13:01 to treat a regular migraine and as i
13:04 mentioned they don’t typically respond
13:06 as well
13:07 and so the one thing that helps us a
13:10 little bit
13:11 is if a patient the one question that we
13:13 ask when a patient presents like this
13:15 two questions really do you have a
13:17 regular menstrual cycle
13:19 so in other words is your cycle
13:21 predictable does it happen every 26
13:23 27 28 days that’s one thing that can
13:27 help us
13:28 and the other thing is is the onset of
13:29 your headache predictable
13:32 so if a patient comes in and says my my
13:34 cycle is every 27 days
13:36 i can tell you my headache starts day 26
13:39 the day before and that’s predictable
13:42 100
13:43 then that helps me because what i can do
13:46 is i can pre-treat her on day 25
13:50 and sometimes it’s called a mini
13:52 preventative treatment
13:53 some and we do that for about five days
13:56 and i’ll talk a little bit more about
13:57 that
13:58 so that’s one of the things in one of
13:59 the approaches and that’s what’s meant
14:01 by short-term menstrual migraine
14:03 prevention
14:04 other things that we can do magnesium
14:07 sometimes can be helpful
14:08 for menstrual migraines so we tend to
14:10 put patients on magnesium
14:12 300 milligrams twice a day
14:15 non-steroidal anti-inflammatories that’s
14:17 what nsaids is so things like naproxen
14:20 um or a leaf or ibuprofen or motrin
14:24 tryptans are helpful for this ergotamine
14:27 and hormones
14:27 so things like the estrogen patch so
14:29 those are all different classes of drugs
14:31 that can be used for this
14:33 um okay uh
14:37 i think we’ll deal with the questions uh
14:39 at the end if that’s okay
14:42 so before we start talking about what
14:44 drugs we use in a little more detail the
14:46 one thing that i really want to stress
14:47 and this is important for
14:48 any patient when you’re treating
14:50 migraine when i see patients in the
14:52 office
14:52 you know we spend a fair bit of time
14:54 talking about education talking about
14:56 lifestyle because
14:57 before we even get to medication
14:59 lifestyle is really one of the most
15:00 important things
15:02 and when we talk about lifestyle we
15:04 start with things like
15:05 sleep hygiene and by that we mean
15:08 regularity and sleep trying to go to bed
15:10 at the same time
15:11 waking up at the same time we know that
15:13 irregularity and sleep
15:14 can trigger migraines and patients if
15:16 you sleep in on the weekend
15:18 you’re more likely to get a migraine if
15:20 you go to bed too late
15:22 if you’re sleep deprived these are all
15:23 triggers so doing the best you can to
15:25 maintain regularity and sleep
15:27 migraine brains hate changes they don’t
15:30 deal well
15:31 with changes whether it’s sleep or
15:33 exercise or diet
15:35 we really don’t do well with changes in
15:36 in our routine
15:38 keeping a diet diary maintaining
15:40 regularity in your diet making sure you
15:42 have three meals a day
15:44 not going for long periods of time
15:46 without eating and
15:47 having a good protein intake first thing
15:49 in the morning exercise we recommend
15:51 three times a week for minimum
15:53 30 minutes at a time being aware of
15:56 medication overuse headache that’s moh
15:58 medication overuse headache so taking
16:00 analgesics or tryptans more than three
16:03 days a week leads to
16:04 medication overuse headache which is a
16:06 chronic daily background headache
16:09 caffeine minimizing that to no more than
16:11 one
16:12 or two cups of coffee or tea a day and
16:15 being careful where your source of
16:16 caffeine comes from if you’re drinking
16:18 starbucks
16:19 or tim hortons be aware that that’s
16:21 probably the equivalent
16:22 in terms of actual caffeine of three or
16:25 four times the amount of caffeine that a
16:27 home brewed coffee would be
16:29 we try and and deal with smoking and
16:32 alcohol related um excess because that
16:35 can certainly trigger migraines as well
16:37 and all of my patients get started on
16:39 magnesium b2
16:41 and vitamin d i save coq10 if they fail
16:45 the first three vitamins it’s a bit
16:46 pricey but it still can help as a
16:48 preventative
16:49 and the trend now is not to put patients
16:51 on butter bur as much
16:54 the dosages of vitamin d are 2 000 units
16:56 and coq10 is 75 milligrams three times a
16:59 day
17:00 these have all been shown in studies to
17:01 have benefit in prevention for migraines
17:03 so these are all useful things to do for
17:06 add-on therapy before we get to the
17:08 actual medications
17:11 so these is this is a list of all the
17:14 the
17:14 acute prevent acute treatments for
17:17 migraine and this
17:18 goes across the board not just for
17:20 menstrual migraine and this is based on
17:22 the canadian guidelines these guidelines
17:24 were published in 2013
17:26 and a group of headache neurologists in
17:29 the canadian headache society
17:30 we basically reviewed and and i’m sure
17:33 there will be webinars on acute migraine
17:35 treatment but
17:36 the studies that were done on acute
17:37 migraine therapy were all
17:39 reviewed and then the recommendations
17:41 that you see on the right hand side of
17:42 the screen were made
17:44 on the basis of the quality of the study
17:47 and what we felt was good practice
17:49 and so those are all the classes of
17:51 medications you see that there
17:52 is cambia which i’ll talk about um
17:55 diclofenac which is an anti-inflammatory
17:57 aspirin ibuprofen naproxen also
17:59 anti-inflammatories and then they get
18:01 into the tryptans
18:02 and the older drugs the ergotamines and
18:04 the opioids
18:06 which have a weak recommendation for use
18:09 so those are guidelines that have been
18:11 made to family doctors and prescribing
18:13 physicians for headache management
18:15 that are used a few words about the
18:17 triptans sumatrip 10 is the first one
18:20 that came out in 1991
18:21 followed by all the others these are all
18:24 available in oral tablets but
18:26 as you can see there are some that
18:27 available are available
18:29 in a melt form or a wafer a couple are
18:32 available in a nasal spray and one
18:34 sumatripten is available in an injection
18:38 they all work the same they are all
18:40 acute therapies but the difference bet
18:42 with a
18:43 couple of them is that they have a
18:44 longer half-life which means
18:46 when you take them they last much longer
18:49 so they’re actually very good choices
18:52 for menstrual migraine because menstrual
18:53 migraines tend to last
18:55 longer than a regular migraine so you
18:57 may have them for two or three days
18:59 so the ones like emerge or neurotryptan
19:02 and frovatryptan
19:04 tend to last more than 12 hours so you
19:06 the advantage to that
19:08 is you don’t need to take it two or
19:10 three times in a day
19:12 for it to be effective for your
19:13 menstrual migraine so we tend to choose
19:15 those
19:16 um for a treatment for us when we’re
19:18 treating patients who have menstrual
19:20 migraine
19:23 so cambia for those of you that may be
19:25 my patients um
19:26 or have seen a headache neurologist may
19:28 have cambia cambia
19:30 is an old drug with a new formulation
19:33 it’s a drug called arthrotec
19:35 diclofenic potassium so it’s been around
19:37 for a long long time but what makes it
19:38 unique is that they’ve now made it
19:40 they formulated it into a powder so by
19:43 doing that
19:44 it works much faster you’ll get some
19:46 you’ll get plasma levels as early as 15
19:48 minutes
19:49 and you just put it into two or two
19:52 ounces of water
19:53 taste minty or aspartame like or not
19:56 aspartate
19:58 anise like and you drink it down quickly
20:02 and it starts to work within about 15 to
20:04 30 minutes
20:06 it doesn’t last it lasts about three or
20:08 four hours and some neurologists who
20:10 deal with migraine and headache a lot we
20:11 tend to combine
20:12 this with one of the slower acting
20:15 triptans that last
20:16 longer because this starts things off
20:19 and then the trip 10 will continue for
20:21 for a good 12 hours
20:24 so something that’s the new kid on the
20:25 block um i don’t know if any of you have
20:28 had this prescribed is called suvex
20:30 you’ve heard me talk about immitrax
20:32 you’ve heard me talk about naproxen or
20:34 aleve
20:35 and what this medication is is a
20:37 combination of
20:39 sumatriptan or imatrix and naproxen and
20:42 what makes it unique
20:44 is that it works faster than each of
20:47 these two drugs individually
20:49 and it lasts longer and this was
20:51 approved in the us in 2008 and was just
20:54 approved in canada
20:55 in 2020 in february of last year
20:58 and they’ve actually done menstrual
21:00 migraine studies with this drug
21:02 and it has shown tremendous benefit in
21:04 the menstrual migraine study that was
21:06 done in 2009 if you’ll see the two
21:08 graphs here there’s one that is two-hour
21:10 pain-free
21:11 if you look at these are two studies
21:14 study one study two the green bar
21:17 is for the suvex the blue bar is placebo
21:21 and in study one and in study two these
21:24 were given to patients who had menstrual
21:25 migraine
21:26 the um patients who were in study one
21:29 and study two
21:30 with menstrual migraine had pain freedom
21:33 at two hours in about 45 to 47 percent
21:36 of the time as compared to placebo
21:39 which was 23 and 22 percent the other
21:42 thing that was significant is if you
21:43 look at the
21:44 next graph that looks at 24 hours
21:46 sustained pain-free what does that mean
21:49 that means they had pain freedom at two
21:51 hours but they maintained that pain
21:53 freedom for 24 hours
21:54 pretty impressive and so the numbers if
21:58 you compare the blue bar to the green
22:00 bar
22:00 still pretty impressive so up to thirty
22:03 percent
22:03 and in some cases in the second study
22:06 over forty percent compared to ten
22:07 percent
22:08 of placebo so subex is actually a very
22:12 good choice for menstrual migraine and
22:14 the other thing that they showed in this
22:15 study
22:16 was that not only did it treat the
22:17 menstrual migraine but it treated the
22:19 menstrual
22:20 related symptoms so the cramping the
22:23 back pain
22:24 the irritability and the dysphoria that
22:27 you feel with menstrual migraine or pms
22:29 related symptoms so
22:30 really good choice so remember that one
22:33 and talk to your family doctor about it
22:35 and it’s a combination of naproxen and
22:37 immatrax
22:38 so again you have to be careful that you
22:40 can take diproxim or anti-inflammatories
22:42 and because sumatriptan has
22:45 cross-reactivity
22:46 with um septra you have to make sure
22:50 that you don’t have
22:51 allergic reactions to that particular
22:53 antibiotics
22:56 okay so i talked to you about some
22:58 short-term studies that we’re looking at
23:00 migraine with mini prevention and that
23:02 short-term study one of them was done
23:04 with anti-inflammatories
23:05 which is naproxen naproxen’s only one of
23:08 them and essentially what they did was
23:10 they looked at patients who had a
23:11 regular menstrual migraine
23:12 a predictable onset of headache and they
23:14 gave them the proximate sodium
23:16 twice a day for five to six days
23:20 and they were able to prevent the
23:21 menstrual migraine from happening
23:24 they also did it with these particular
23:26 tryptans so that’s immatrax
23:28 neurotryptin is emerge zolmatrypten is
23:31 zomig and frovatrypten
23:33 is frova and what they did with these
23:35 patients is they started these
23:36 medications
23:37 two days before the migraine was to
23:39 begin and they were taking them twice a
23:42 day
23:42 for anywhere from five to seven days and
23:44 they all showed some benefit
23:46 in preventing that menstrual migraine
23:48 from occurring
23:51 they also did a study using the
23:53 estroderm patch
23:54 and the estroderm patch was applied 48
23:57 hours prior to the menstrual migraine
23:59 starting
24:00 and the patch was changed at day three
24:02 another patch was applied
24:04 and this also showed some benefit when
24:07 they did this with the oral
24:08 contraceptive
24:09 it was less effective so the patch
24:11 seemed to work not great numbers
24:14 but certainly some benefit what i’ve had
24:16 some luck with
24:17 is combining the estroderm patch and the
24:20 naproxen
24:21 where i give them two i do naproxen
24:23 preventatively
24:24 and i give them the estroderm patch
24:26 preventatively so the combination of the
24:28 two
24:28 seems to work quite well so now getting
24:31 back to our patient
24:32 now she’s 35 headaches have been
24:35 controlled using topiramater topomax for
24:37 a preventative she’s also been on botox
24:40 she’s now down to having three headaches
24:42 a month and she treats them with max
24:44 alter rhizotripten but now she wants to
24:46 get pregnant
24:48 so what do we know about migraines in
24:50 pregnancy well the good news
24:52 is that up to about 70 percent of women
24:54 get better
24:55 during pregnancy so that’s the good news
24:58 um
24:59 the bad news is that the 30
25:02 of women who don’t get better during
25:04 pregnancy get worse
25:07 some of them get worse during the first
25:09 trimester alone
25:10 and then they tend to improve but
25:12 there’s a small percentage of them
25:14 that get worse and continue throughout
25:16 the entire pregnancy
25:17 as well as throughout breastfeeding if
25:20 they’re going to breastfeed
25:21 and they can be very challenging because
25:23 these headaches can be very very severe
25:26 something else can also happen where
25:27 they may experience a new onset of aura
25:30 so they may have never had aura before
25:32 and they start to have these auras
25:34 whether they’re visual or whether they
25:36 start to have numbness or tingling
25:38 and these are frightening because there
25:39 are many other conditions
25:41 and you can’t just assume that it’s
25:43 migraine so we still we tend to start
25:45 investigating these women
25:46 to make sure that it’s not something
25:48 else
25:50 if they do well during pregnancy and
25:52 their headaches go away
25:53 chances are quite good that they’re
25:55 going to continue to stay away
25:57 after once they’re breastfeeding until
26:00 they stop breastfeeding and then they’re
26:02 likely to come back
26:06 so how do we treat these patients it’s
26:08 really quite challenging because there’s
26:09 not a lot of things that we can give
26:10 them
26:11 we tend to approach a do no harm
26:13 approach in the first trimester in
26:16 in most cases we try not giving them
26:18 anything
26:19 if we can tylenol is quite safe
26:22 during pregnancy and breastfeeding so
26:24 that tends to be our go-to
26:26 analgesic the very often there’s nausea
26:29 so we use things like metaclopramide or
26:31 maxiran
26:32 and it can be given orally or
26:34 intravenously
26:35 promethazine can also be used around
26:38 dancitron and these are the antimedics
26:40 that they tend to use in cancer patients
26:42 or chemo patients
26:43 we avoid opioids during pregnancy and
26:46 we used to use magnesium sulfate but now
26:49 because of some potential skeletal
26:51 abnormalities and bone loss in the in
26:53 the fetus
26:54 we avoid that it can be used in high
26:56 doses in the emergency room
26:57 once or twice but we not we’re not
26:59 giving it preventatively like we used to
27:04 tryptans were never considered safe up
27:07 until three years ago
27:08 um and when sumatriptan first came out
27:12 and now with all the tryptans that have
27:14 followed
27:14 there’s something called a pregnancy
27:16 registry and basically what that means
27:18 is when a patient
27:20 has been taking a tryptan if they become
27:23 pregnant
27:24 while they’re taking it they’re entered
27:26 into the pregnancy registry for that
27:28 particular trip to end and so
27:29 sumatriptan which is the one that’s been
27:31 around the longest
27:32 has over 5000 patients in the pregnancy
27:35 registry and so
27:36 there really haven’t been any published
27:38 increased rates of defects or
27:40 spontaneous abortion
27:41 or other adverse pregnancy outcomes in
27:44 comparison to the normal population so
27:46 with that many patients in 2017
27:50 they basically said you’re okay to use
27:52 sumatriptan
27:53 during your pregnancy if you need to but
27:56 again we try and avoid it if we possibly
27:58 can in the first trimester and i
28:00 wouldn’t recommend using it
28:03 there’s no data yet on drugs like ella
28:05 trypton
28:06 or relpax or phrovatryptam because we
28:09 don’t have a high enough number in the
28:11 pregnancy registry as yet
28:15 in terms of prevention there are some
28:17 medications that we tend to use i mean
28:20 cyproheptadine is
28:21 rarely used but it is a preventative
28:24 it doesn’t have great data to support
28:26 its use
28:27 fluoxetine or prozac and sertraline can
28:30 be used but again
28:31 not a lot of studies to support their
28:33 their benefit
28:34 we tend to use beta blockers so
28:36 propranolol pindilol
28:38 or labetalol and also amitriptyline can
28:41 be used during pregnancy or elevil
28:43 but again these are these are used in
28:46 the second trimester and third trimester
28:48 we avoid them otherwise so now she’s 16
28:52 weeks pregnant
28:53 her headaches are persisting they’re
28:55 happening two or three times a week
28:56 she’s vomiting she’s not able to work
28:58 and she can’t take acute medications
29:00 because of the vomiting
29:02 so at this point in time we would start
29:04 her on a preventative and the
29:05 preventative we would probably go with
29:07 amitriptyline because she’s not sleeping
29:08 well
29:09 she’s developed some anxiety we could
29:12 use propranolol
29:13 as well but we have to stop some of
29:15 these preventative medications prior to
29:17 delivery because they may affect the
29:19 fetus
29:21 and we could use aspirin but we again
29:24 tend to stop it prior to delivery
29:27 i tend to avoid aspirin completely
29:29 during pregnancy and i’ll stick with
29:31 tylenol
29:32 and you could even use weave and use
29:34 tylenol with codeine in some
29:35 circumstances
29:37 again we tend to use non-medication
29:40 approaches as much as we can
29:41 so i refer them on for massage therapy i
29:44 use essential oils
29:45 there’s something called cephaline you
29:47 may or may not be familiar with it
29:49 um it’s it’s um it’s like a
29:52 stimulator a neural stimulator it’s um
29:55 it’s something that you can
29:56 uh put on if you’ve seen it
30:00 advertised they sell them at costco it
30:02 almost looks like a
30:03 star wars headband that you wear on your
30:06 head
30:07 and it gives impulses but it’s not it’s
30:10 it’s not going to do any harm
30:11 the data is not overwhelming but it’s
30:14 something that
30:15 may give them some added benefit and
30:17 it’s not going to harm them in any way
30:18 so you really pull out all the stops
30:20 for things that are non-pharmacological
30:22 during pregnancy
30:25 we also look at supplements but again
30:28 checking with the
30:29 obg because some of them really don’t
30:31 want supplements
30:32 um during pregnancy and then sometimes
30:35 nerve blocks will be helpful i prefer
30:37 patients for nerve blocks um
30:38 we treat the occipital nerves the back
30:41 or the supraorbital nerves just above
30:43 the brow
30:44 acupuncture may be useful um and
30:47 magnesium sulfate we tend not to use
30:49 anymore
30:52 again we focus on lifestyle hydration
30:54 exercise sleep hygiene and caffeine all
30:57 the things that i mentioned to you
30:58 before but we really tend to
31:00 emphasize that on a great deal during
31:02 pregnancy
31:03 because we can’t really use medications
31:05 as much as we would like to
31:08 botox is something that is always
31:10 questioned during pregnancy
31:12 and although there are no reports of
31:15 anything
31:15 occurring untoward using botox in
31:17 pregnancy we tend to avoid it
31:20 i have probably three patients that i’ve
31:22 given botox to
31:23 during breastfeeding again there haven’t
31:26 been any reported issues associated with
31:28 it
31:29 but no one in the company or there is no
31:32 one that will tell you that you can
31:34 use it um there really haven’t been any
31:37 published papers to say that it really
31:38 causes any harm
31:40 or that it’s contraindicated it’s really
31:43 a question of risk versus benefit
31:45 and the patients that i’ve used it in
31:46 were patients that had it prior to
31:48 pregnancy
31:49 and had severe emesis and throwing up
31:51 and severe migraine that they really
31:53 couldn’t even bond with their baby
31:55 after delivery so i i used it in um
31:58 in the postpartum period um while they
32:01 were breastfeeding
32:03 so these are just i don’t expect you to
32:05 read this whole slide these are just
32:06 some of the conditions that we get
32:08 concerned about when a patient presents
32:10 with
32:10 migraine-like headaches in the
32:12 postpartum period
32:14 or even pre-partum eclampsia idiopathic
32:18 intracranial hypertension we always
32:20 worry about a bleed in the brain
32:22 we worry about a tumor a pituitary bleed
32:25 we worry about something called cerebral
32:27 venous thrombosis
32:28 where you get clotting in the venous
32:30 system
32:31 and then just some very very rare
32:33 conditions but the point is that even
32:35 though they may have a history of
32:36 migraine
32:37 if things change and if they develop an
32:40 aura
32:40 or if there’s a significant worsening of
32:42 headache and they haven’t been
32:43 investigated it may be time to do
32:45 something
32:46 we tend to investigate by doing mri
32:48 scans during pregnancy rather than ct
32:50 scans because of the radiation
32:52 mri scans are safe there are some
32:54 centers that won’t do them during the
32:56 first trimester
32:57 so we tend to wait if we can if it’s an
32:59 urgent situation
33:01 there isn’t a problem there haven’t
33:02 really been any reported problems doing
33:04 mri during pregnancy
33:08 so postpartum um the things that i’ve
33:10 just mentioned are issues particularly
33:12 if they’ve had epidurals we think about
33:14 a spinal fluid leak
33:15 um and we always have to have a
33:18 heightened level of awareness to make
33:19 sure that we’re not just calling this a
33:21 migraine
33:22 we have to think about other things and
33:23 have the high index of suspicion for
33:25 other conditions
33:26 that it could be mimicking and also
33:30 in lactation um the same rules apply for
33:32 the medications that we use so tylenol
33:35 is an analgesic
33:36 a tryptan if we need to if you’re using
33:39 a tryptam we tend to use sumatriptan
33:41 injection and it’s the pump and dump
33:44 where you
33:45 um you give yourself the injection and
33:47 then you pump your breast milk dump it
33:49 for four hours and then you’re good to
33:50 go
33:51 breastfeeding again
33:55 i think i’ve mentioned that already
33:58 these are the hail categories and
33:59 basically this is how they categorize
34:01 the medications
34:04 in terms of safest safer moderately and
34:06 contraindicated
34:08 there used to be mother risk there no
34:09 longer is so now we refer patients to
34:12 toxnet
34:12 um as a reference for what’s safe i
34:15 always recommend my patients contact
34:17 them or read about it
34:18 before they take any of the medications
34:20 that are prescribed for them
34:23 okay so um this patient is now 20 is 26
34:27 this is a different patient and she was
34:29 diagnosed with
34:30 migraine with aura in her teen years so
34:33 the or as you recall
34:34 could be the visual symptoms the
34:36 numbness and tingling this one in
34:37 particular had visual auras
34:39 um they were called scintillations so
34:42 zigzag patterns a lacy doily pattern
34:45 and fortification spectra which is
34:47 basically almost like a
34:49 if you look at a starry or a zigzag
34:52 pattern that’s half of a
34:54 half of a lacy doily almost on the
34:57 outside of her peripheral vision
34:59 and her aura would come on lasting about
35:01 five or ten minutes and after that the
35:02 migraine would follow
35:04 she has about five migraines a month she
35:06 has one severe attack during her
35:08 menstrual cycle and she uses
35:09 anti-inflammatories about five times a
35:11 month to manage them
35:13 she wants to start the birth control
35:15 pill
35:16 what do we tell her what are our
35:19 concerns in using the birth control pill
35:21 in migraine so do we tell her to go
35:24 ahead
35:25 do we tell her she can’t not she cannot
35:27 take it at all with any kind of aura
35:29 do we tell her to start the progesterone
35:31 only pill if she has aura or she can
35:34 start the low
35:35 dosed um she can start low dose that
35:38 should be estrogen sorry not best
35:40 low dose estrogen or progesterone only
35:42 in migraine with aura
35:44 and visual aura and if the aura worsens
35:46 or the headache increases stop it
35:49 so essentially the answer is c and d and
35:51 we’ll talk about why
35:52 so she can start progesterone only in
35:55 migraine with aura
35:56 if she has a visual aura or she can
35:59 start the lowest
36:00 dose estrogen or progesterone only in
36:02 migraine with aura if it’s a visual aura
36:05 if it worsens or changes she should stop
36:07 it
36:09 and the reason is that we worry about
36:10 stroke and we worry about stroke risk in
36:13 migraine with aura
36:14 so if you have migraine without aura
36:18 your stroke risk is no higher than the
36:19 general population in a woman your age
36:22 where things start to change is when you
36:24 have migraine with aura
36:26 and we don’t think that if you have
36:28 visual
36:31 visual aura with your migraine it’s that
36:33 much different
36:34 than the migraine that doesn’t have aura
36:37 so if they’re uncomplicated visual we
36:39 don’t get too
36:40 concerned however your aura
36:43 does increase your stroke risk very
36:45 slightly if you have migraine with aura
36:48 it does increase stroke risk if it’s
36:50 once a month
36:51 you have a two-fold increase if it’s
36:54 once a week
36:55 it’s a four-fold increase in stroke
36:58 both oral contraceptives and migraine
37:00 with aura independently
37:02 increase the risk of stroke so if you’re
37:04 on the birth control pill
37:05 your stroke risk is increased if you
37:08 have a history of migraine with aura
37:10 your stroke risk is increased you put
37:11 them together your stroke risk is higher
37:14 even so it’s um the gr
37:17 and the stroke risk is higher it’s
37:19 greatest when you have a high dose of
37:21 estrogen
37:22 so greater than 50 micrograms of
37:24 estradiol
37:25 it may be a minimal increase in the risk
37:28 if you have
37:30 um oral contraceptives with less than 20
37:33 or 25
37:34 micrograms of estrogen even if you have
37:36 a simple aura
37:38 so in other words the message is if you
37:41 have
37:42 migraine with visual aura you want to go
37:44 on the oral contraceptive
37:46 the lowest possible dose of estrogen
37:48 would be the way to go
37:50 without significantly increasing your
37:52 risk
37:55 the other possibility is to consider
37:57 progesterone only because progesterone
37:59 will not
37:59 increase the risk of stroke in fact it
38:02 may actually reduce migraine frequency
38:04 and severity
38:06 and it may be safer than continuous oral
38:08 contraceptives and migraine with aura
38:11 so this is a chart that’s very busy um
38:15 and if you look across the top a-c-o-g
38:18 is the american college of obstetrics
38:20 and gynecology
38:21 w-h-o you’ve all heard about that by now
38:24 with covet the world health organization
38:26 and ihs is the international headache
38:28 society
38:30 so if you have headache that’s
38:31 non-migranous this is in regards to
38:34 should you could you start a patient on
38:36 the pill
38:37 and if you have a headache that’s
38:38 non-migraines everybody’s happy go ahead
38:41 and go ahead and start it if you have
38:43 migraine without aura
38:45 the obg people and the who
38:48 said yep no problem so migraine without
38:51 aura
38:52 if you’re under 35 everybody’s still
38:55 happy
38:55 except for the international headache
38:57 people they say do a risk assessment
38:59 just be careful if you’re over 35
39:02 everybody seems to agree
39:04 risk assessment and the eight
39:07 the guyanese people in who say the risk
39:10 outweighs the benefit
39:12 so they hesitate on that one if you’re a
39:15 smoker
39:16 both the gynae people and the who so the
39:19 risk outweighs the benefit the
39:21 international headache society basically
39:23 says stop smoking before you start
39:25 the oral contraceptive where we get into
39:28 a bit of an issue
39:29 um and a bit of a disagreement is that
39:31 you have when you have patients who have
39:33 migraine with aura you’ll see definite
39:36 crosses
39:37 both with the gynae and the world health
39:39 organization
39:41 that migraine with aura no birth control
39:44 pill
39:45 period that’s it however when you have
39:48 the international headache um society
39:51 says
39:51 essentially do a risk assessment um
39:54 if you’re a smoker stop smoking if you
39:58 have
39:58 migraine with simple visual aura you can
40:01 start
40:02 a low-dose estrogen oral contraceptive
40:06 if something happens where your auras
40:08 increase or change
40:09 you stop it and if you have additional
40:12 risk factors on the bottom for stroke
40:14 hypertension obesity diabetes
40:16 you do a risk assessment and you
40:17 determine based on each patient
40:19 if the risk is higher than the actual
40:21 benefit
40:22 so they’re slightly different the
40:24 international headache people
40:26 are a little less conservative the who
40:29 and the gynecology people in the u.s are
40:32 definitely more conservative
40:36 the bottom line is you need to do risk
40:38 and benefit assessment for each
40:40 individual patient
40:41 you need to caution the patient and
40:44 patients need to know if they’re started
40:46 on oral contraceptive or hormone
40:48 replacement therapy
40:49 they need to watch themselves for a
40:51 change in the frequency of the headache
40:53 an escalation in the severity or a
40:55 change in the pattern of the headache
40:58 if they’ve had simple visual auras and
40:59 all of a sudden now they’re developing
41:01 numbness or tingling or paralysis or
41:03 difficulty with their speech
41:05 then they need to contact their
41:06 physician if their auras
41:08 start just when you started the birth
41:10 control pill and they’ve never had auras
41:12 before
41:13 they need to tell somebody about it or
41:15 if they have any new associated symptoms
41:17 if things have changed
41:19 they need to contact their physician we
41:21 always recommend if you’re starting
41:22 hormone replacement therapy
41:24 a headache diary and always use the
41:27 lowest possible
41:28 estrogen dose in the continuous birth
41:30 control pill that you can
41:33 monitor the use of tryptans and monitor
41:35 the frequency of the use of tryptons
41:38 when you’re combining the two
41:42 um the studies are poor we don’t as i
41:45 said they haven’t been done for quite a
41:46 number of years we don’t have
41:48 um you know i mean we have different
41:50 methods
41:52 you’ll read one study that will tell you
41:53 this is the stroke risk you’ll read
41:55 another study that will
41:56 contraindicate or contradict that
41:59 particular study and say no this is the
42:00 actual stroke risk
42:02 you’ve seen that we can’t even get
42:03 agreement between large bodies
42:06 such as the who the obg school of
42:09 thought and the international headache
42:10 society
42:11 but essentially i think that if the
42:13 message you take away from this
42:15 is if you have migraine without aura
42:18 and you and someone wants to go on the
42:20 oral contraceptive again the lowest dose
42:23 of estrogen possible
42:24 if you go on the oral contraceptive or
42:27 hormone replacement and you get a change
42:29 in pattern
42:30 of your headache or a new onset of aura
42:32 it’s time to reconsider
42:33 and look at something else or look at an
42:36 alternative at that point
42:38 and if you have migraine with aura
42:39 that’s anything but visual
42:41 you should avoid estrogen containing
42:44 oral contraceptives and consider
42:46 progesterone only
42:49 so now jen’s 48 her migraines have
42:52 increased they’re less predictable
42:53 she’s had a change in the character of
42:55 the headaches they’re lasting longer
42:57 they’re not occurring every 28 days
42:59 they’re the triggers aren’t really
43:01 predictable they’re less responsive to
43:03 treatment they happen every 10 to 15 per
43:05 month
43:06 so they’re much more frequent she’s
43:07 sleeping poorly she’s gaining weight
43:11 she finds that her mood is actually
43:12 affecting her as well so something’s
43:14 changing and she’s 48.
43:17 how do we manage her well do we consider
43:20 imaging her
43:21 the answer is yes because it’s a change
43:23 in her pattern and she’s 48 years old
43:26 do we try a non-pharmacological approach
43:28 always
43:29 well that’s part of your armamentarium
43:32 even before you start medication so we
43:34 look at the vitamins we get her to keep
43:35 a diary
43:36 we look at her lifestyle has anything
43:38 changed so we reveal
43:40 reevaluate that all the time when they
43:41 come in and there’s been a change
43:43 maximize her acute therapy if she’s been
43:45 taking trip tens maybe we want to try
43:47 something different because
43:49 you all know that if you’ve been on a
43:50 trip 10 or something for six months
43:52 sometimes you need to change consider
43:55 prophylaxis or a change in your
43:56 prophylactic
43:58 all of the above so yes we do all of
44:00 these things to manage her
44:01 and we do investigations as well
44:04 something happens when we approach
44:05 menopause something happens to our
44:07 hormones we get
44:08 fluctuations and before we get a drop in
44:12 estrogen
44:13 we get fluctuations it goes up it goes
44:15 down and it’s a
44:16 wavy pattern before it eventually starts
44:20 to peter down
44:21 so every time you get a rise in a fall
44:23 and a rise in a fall
44:25 and anybody who’s headache prone with
44:27 menstrual migraines for example
44:29 that’s when they’re going to get the
44:30 storm before things eventually peter out
44:33 so typically that’s what happens and if
44:36 you’ve got a woman who starts to get
44:37 worsening headache and she still has her
44:39 period
44:40 you can almost bet that within six
44:42 months she’s gonna start to get
44:43 irregularity in her menstrual cycles
44:45 and she’s heading towards menopause um
44:48 and it usually is is associated with the
44:50 fluctuations in her estrogen levels
44:53 um but the good news is it’s probably
44:56 going to get better
44:57 after the menses uh settles down in
44:59 about 70 percent of women
45:02 um so she’s going to ask you specific
45:04 questions
45:05 are her headaches going to get better
45:06 after menopause um
45:08 can she use the same tryptanes to treat
45:10 them does hormone replacement therapy
45:13 help which one should she take and the
45:15 question on top of everybody’s mind is
45:17 well why
45:18 not just do a hysterectomy the answers
45:20 are
45:21 will the headaches get better after
45:22 menopause in most cases yes but you may
45:25 need prevention to get you through this
45:27 unstable period
45:28 in the meantime can you use the tryptans
45:30 probably yes and the only
45:32 reason i say absolutely is because she’s
45:35 48
45:35 make sure she hasn’t developed heart
45:37 disease make sure she’s not smoking
45:39 make sure she doesn’t have any other
45:40 cardiovascular risk factors like
45:42 hypertension
45:44 does hormone replacement therapy help
45:46 yeah it might and you might consider low
45:48 dose hormone replacement therapy in this
45:50 situation to even out
45:52 those hormonal fluctuations and what
45:55 about a hysterectomy
45:56 the answer is no there’s no evidence
45:58 that a hysterectomy makes
46:00 any difference and in fact it may make
46:01 the situation worse
46:03 um surgical menopause is not the answer
46:06 for this situation at all so if you’re
46:08 tempted don’t do it
46:12 we don’t typically use hormone
46:13 replacement therapy as a first line
46:16 we would only use it short term and we
46:19 tend to use
46:20 prophylaxis that we use for migraine if
46:22 that hasn’t worked
46:23 then in conjunction with the
46:24 gynecologist we may consider hormone
46:26 replacement therapy
46:28 but typically if they’re having other
46:30 things like hot flashes
46:31 dryness of the skin memory related
46:34 issues
46:34 that’s when we’ll go to hormone
46:36 replacement therapy it’s not
46:38 it’s not common to use that strictly for
46:40 the headaches and the migraines
46:41 themselves
46:43 because the hormone replacement therapy
46:44 can actually make the headaches worse
46:47 and if you find that the headache
46:49 headaches are worse with the hormone
46:51 replacement therapy we try reducing the
46:53 doses
46:54 we use non-cycling so that we give them
46:56 to the continuously
46:58 we may change from a conjugated estrogen
47:00 to pure estrogen
47:02 switch it to a patch um we might
47:04 manipulate it in a few ways to try and
47:06 minimize the headache but there are some
47:08 women that
47:08 really cannot tolerate hrt at all um
47:11 so as i said seventy percent of women
47:14 will get better
47:15 um and the worsening around the
47:17 perimenopause is not at all unusual
47:19 and we could use hrt so where does that
47:22 leave us um
47:24 just a few little pearls to take away
47:27 migraine with aura
47:28 increases the stroke risk two to four
47:30 times in women
47:31 um the baseline absolute risk is still
47:34 very low so
47:35 i mean when we say the stroke risk risk
47:37 is increased i don’t want you walking
47:38 away thinking oh my god
47:40 i have migraine with aura i see flashing
47:42 lights so i’m going to have a stroke
47:43 it’s very low
47:44 it’s still anywhere between five and ten
47:46 women in a hundred thousand per year
47:49 so really low numbers estrogen
47:52 oral contraceptives are not absolutely
47:54 contraindicated in migraine without aura
47:57 and the risk of stroke
47:58 may be dose related in the oral
48:01 contraceptive so higher estrogen
48:03 higher stroke risk migraine with aura
48:06 non-estrogen containing contraception is
48:09 favored
48:10 and if migraine with aura and there is
48:12 choice use the lowest
48:14 estrogen containing ocp follow these
48:17 patients closely for a change in aura if
48:19 you are started on
48:20 ocp or hr or homo replacement therapy
48:24 then if you have any change in your
48:25 headache pattern escalation or
48:27 association with aura get in touch with
48:30 your doctor
48:32 and then we have something called
48:33 complex auras that are very
48:34 controversial
48:35 many people will come in and say they
48:37 have hemiplegic migraine
48:39 where they have numbness on one side
48:41 that’s not truly a hemiplegic migraine
48:43 so be very careful with that and make
48:45 sure that
48:46 if someone’s diagnosed you with that you
48:47 get to see a headache specialist because
48:49 true homeoplagic migraine
48:51 in 30 years of practice i’ve really only
48:53 seen about three true cases
48:55 um so make sure that that’s clarified
48:58 very carefully
48:59 so thank you for your attention and i
49:01 think we can take questions at this
49:14 point