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INTRODUCTION

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Headache, cerebrovascular disease, epilepsy, and neuroimmunological conditions will be discussed in relation to specific women’s issues in the childbearing age, pregnancy, peripartum, and menopausal periods.

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Special considerations must often be taken when caring for female inpatients, from not only diagnostic but also therapeutic perspectives. Hormonal changes are widely recognized to have an impact on almost all neurological conditions. Pregnancy and puerperium may modify the nature or severity of a neurological condition, while predisposing women to the development of specific conditions, such as postpartum angiopathy. Menopause may carry specific management implications, such as seizure exacerbation with hormone replacement therapy. Finally, choice of therapy is heavily influenced by the potential for teratogenicity in multiple neurology subspecialties from multiple sclerosis to epilepsy.

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HEADACHE IN WOMEN

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Women of childbearing age

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Impact of sex hormones on migraines
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The observation that migraine is three times more prevalent in women than in men,1 and the influence of reproductive milestones on migraine support the long-standing recognition of the impact of sex hormones on migraines. Menstrual migraine is one of many clinical examples of the links between estrogen and migraine. It is hypothesized that a fall in estradiol levels after prolonged estradiol elevations, as observed before menses, is responsible for such links.2

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Pure menstrual migraine is defined as migraine without aura occurring exclusively on day 1±2 of menstruation in at least 2 of 3 menstrual cycles.3 Menstrual migraine attacks are typically more severe, longer in duration (with higher rates of status migrainosus), and less responsive to acute attack treatment, as compared to nonmenstrual migraine attacks.4 As a result, women with menstrual migraines may be more likely to require Emergency Department (ED) visits for treatment of migraine attacks.

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Taking a migraine history in women should include a screen for hormonally influenced migraines including age at onset of headache in relationship to menarche, and the impact on headache frequency and severity by:

  • use of oral contraceptive pills (OCP) (continuous versus cyclical use, combined versus progestin-only, indication of use)

  • previous pregnancies and breastfeeding

  • previous hormonal manipulation (eg, for infertility, irregular cycles, etc.)

  • partial or total hysterectomy5

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Multiple therapeutic strategies may be employed to reduce the frequency and severity of menstrual migraine attacks. Of note, interventions focused on menstrual migraines are more likely to be effective in pure menstrual migraine than menstrually related migraine (ie, women with migraine attacks outside of the menstrual window). Acute (abortive) therapy can be provided as in any other migraine attacks. Short-term prevention during the menstrual window of vulnerability may be initiated in women with predictable onset of menstrual headache and lack of pain freedom with acute therapy. Triptans may be given twice a day starting 2 days before and through 3 days of menstruation. Alternatively, naproxen sodium 550 mg twice daily may be given starting 7 days ...

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