Menopause, Migraine, and Hormone Therapy [transcript][audio]

Guest: Dr. Jelena Pavlovic

Presenter: Neal Howard

Guest Bio: Dr. Jelena Pavlović is a practicing Neurologist and Headache Specialist at the Montefiore Headache Center and is an Assistant Professor at the Albert Einstein College of Medicine in Bronx, NY.  Dr. Pavlović is also a physician-scientist who holds a PhD in Molecular Medicine. Her research interests broadly focus on hormonal regulation of migraine in women and specifically she aims to answer the question of how hormonal fluctuations affect migraine symptoms during the menstrual cycle and across the transition to menopause. Dr. Pavlović is board certified by the American Board of Psychiatry and Neurology. She is a member of the American Academy of Neurology (AAN), the American Headache Society (AHS), and the International Headache Society (IHS). She has published extensively on the topic of migraine in women and is funded by the National Institutes of Health/National Institute of Aging (NIH/NIA) to conduct research on this topic.

 Segment Overview: Dr. Jelena Pavlovic, a presenter at the North American Menopause Society (NAMS) Annual Meeting (Oct 2017), a practicing Neurologist and Headache Specialist at the Montefiore Headache Center and a physician-scientist who holds a PhD in Molecular Medicine discusses her presentation on a study that she is lead author on linking migraines, heart disease, and hormones.

TRANSCRIPT – Menopause Therapy

Neal Howard: Hello and thank you so much for tuning into the program. I’m your host Neal Howard here on Health Professional Radio. Our guest today is Jelena Pavlovic. She’s a presenter at the North American Menopause Society or NAMS annual meeting that is being held this month. She’s joining us here today on the program to discuss her presentation on a study that she’s the lead author of that links migraines, heart disease and hormones. Welcome to the program Dr. Jelena Pavlovic. How are you?

Dr. Jelena Pavlovic: Well thank you very much. I’m well. How are you? And thank you for your interest in this topic and for having me on.

N: We’re all familiar with menopause. What it is, who it affects and how, but I understand that you led a study that linked heart disease, migraine, headache and hormones. How do the three come together?

P: I am a neurologist and specifically I am a headache subspecialist which means that I spend majority of my clinical time taking care of people with migraine. And because migraine is highly prevalent among women that is it has, it is about three times more common in women than men. I spend majority of my clinical time taking care of women with migraine and I spent the rest of my time doing research on hormonal relationship of migraine and its influence – the hormonal influence on migraine. How are the two related is that migraine has been long associated with hormonal fluctuation and it has also been associated with cardiovascular disease and lately this has gathered increasing attention. The majority of the available data that we have had on the association between migraine and cardiovascular disease has really been in migraine with aura which is a specific subtype of migraine and ischemic stroke which is a most common type of stroke. Neurologists know this well. But with the other evidence of migraine being associated more so with other cardiovascular disease and with combined cardiovascular disease is somewhat newer and has been somewhat conflicting in women of different age groups and among different subtypes of migraine.

N: Are these women that are in different age groups, are we talking more in women that are menopausal or pre-menopausal or postmenopausal? Who is more affected by these three linked together? The hormones, the migraines and the heart disease.

P: Migraine is affected by hormones throughout a woman’s lifespan. We know that migraine is most highly prevalent in women of reproductive age that is in the most where the highest percent of women of population have migraine is in the 30s. So, in their 30s one in four to one in three women has migraine. Those are really staggering statistics how common migraine is. The research on Association of Migraine with cardiovascular disease has been done in the subgroups, initially in the subgroup of women who are over age 45 in the women’s health study. And there’s the relationship to increase cardiovascular disease was seen only in women who had migraine with aura. A more recent study, Nurses Health Study which looked at women of age 25-42 showed 50% higher risk for developing major cardiovascular disease in women who had migraine. This is why it was of interest to look in another large women’s health study particularly in this type Women’s Health Initiative and see what they further tried to examine this relationship of migraine with cardiovascular disease events. And also the additional piece which has so far not been looked at, see if there is an interaction with hormone therapy use in this population and women with migraine. The advantage of doing this within the Women’s Health Initiative has been that Women’s Health Initiative was structured two ways. There’s an observational study cohort and the hormone therapy trial. It was a randomized clinical trial and within this hormone therapy trial we could see the effect if the hormone therapy had an effect on this relationship.

N: Was there a difference in the types of therapy that were administered as far as hormone therapy?

P: Yes. There were two arms in the Women’s Health Initiative of estrogen alone and estrogen and progesterone combined but we did not see the difference. Most importantly in the observational study, just observation of the women and these women were aged 50 to 79 at a time of recruitment into the Women’s Health Initiative. We did not see an increased risk of cardiovascular, new cardiovascular disease related events in women who had history of migraine. That was the first very important piece of information that we observed and it is important to notice that the Women’s Health Initiative does not contain information on migraine with aura. The aura information, we could not discern so it is unclear what if we had aura information, if we would have been able to substratify and looked at that just subgroup of population of whether we would have seen an effect similar to the Women’s Health Study that had previously been observed. And the second part is that in the hormone in the trial part where the hormone therapy was given to women, we did not see that hormone therapy either estrogen or estrogen and progesterone act as a modifier of this association between migraine and cardiovascular disease.

N: If the risk factors for cardiovascular disease are totally removed, that’s an impossible thing to do, in your opinion with those risk factors with their removal, reduce the relationship between hormones and migraine in menopausal women.

P: This study was not aimed at answering that and I don’t think that there is a study that can answer that. The effect of hormones because of the endogenous changes in hormones in women is well known on migraine. And on how migraine presents in women and triggers attack is this component of menstrual migraine and perimenstrual attacks in those women over productive age. We know less about it in women who are perimenopausal and who are undergoing really robust hormonal changes that are no longer orchestrated in a way they are in reproductive age women. These can also affect migraine and we’ve seen in other studies which have been a part of that oftentimes this leads in those women who have history of migraine, perimenopausal time can lead to increased frequency of migraine attacks during that stage. This leads to a lot of complications of the disease and a great burden of disease of their headache attacks. Hormone therapy has been used effectively in perimenopausal women to treat some of their headache attacks especially those that are hormonally sensitive. The challenge is that because of the cautions of surrounding the use of combined oral contraceptives also known as birth control and because their association with the increased stroke risk in women who have migraine with aura. There have been strict guidelines that caution against use of birth control in women with migraine and a brief recommend complete avoidance in women with a history of migraine with aura. These guidelines often get extrapolated into the hormone therapy and with the suggestion that maybe perhaps it’s also unsafe to use hormone therapy in women with migraine. There has been no evidence or such guidelines but this is common. You can see how this can become convoluted and how women who were cautioned at age 30 not to use oral contraception can then be hesitant to use it in their late 40s and 50s while they’re undergoing perimenopause. With the recent changes in hormone therapy guidelines by the North American Menopause Society suggesting use of them for treatment of symptoms of perimenopausal women, we’ve thought it’s very important to try and get the best possible evidence that we can on the safety of hormone therapy use in women with migraine. This particular study although the new guidelines suggesting the use of hormone therapy in perimenopausal women, the WHI was primarily done in older women. The data is not exact because the women were aged 50-79, some of these women were in an older age group. The data cannot be directly extrapolated but suggest that this is inline with prior work and further suggests the line of evidence that hormone therapy should be considered in women with history of migraine, when appropriately used and when there are no other contraindications to it.

N: Then we can learn more online where?

P: The International Headache Society website and at American Headache Society and AMS migraine. The information on the WHI – the Women’s Health Initiative is also available online on the Women Health Initiative website which is whi.org.

N: Thank you for joining us today and I’m hoping you will come back.

P: Thank you so much. Thank you for your interest.

N: Dr. Jelena Pavlovic, practicing neurologist and headache specialist at the Montefiore Headache Center. Also an assistant professor at the Albert Einstein College of Medicine in the Bronx. Transcripts and audio of the program are available at health professionalradio.com.au and also at hpr.fm. Subscribe to the podcast on iTunes, listen in and download a SoundCloud and be sure and visit our affiliates page when you visit us at healthprofessionalradio.com.au and also at hpr.fm.

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