Lauritsen Clinton G, Chua Abigail L, Nahas Stephanie J
Department of Neurology, Thomas Jefferson University, 900 Walnut St. Suite 200, Philadelphia, PA, 19107, USA.
Hartford Healthcare Headache Center, 65 Memorial Road Suite 508, West Hartford, CT, 06109, USA.
Curr Treat Options Neurol. 2018 Mar 6;20(4):7. doi: 10.1007/s11940-018-0492-7.
Menopause is a life-changing event in numerous ways. Many women with migraine hold hope that the transition to the climacteric state will coincide with a cessation or improvement of migraine. This assumption is based mainly on common lay perceptions as well as assertions from many in the healthcare community. Unfortunately, evidence suggests this is far from the rule. Many women turn to a general practitioner or a headache specialist for prognosis and management. A natural instinct is to manipulate the offending agent, but in some cases, this approach backfires, or the concern for adverse events outweighs the desire for a therapeutic trial, and other strategies must be pursued. Our aim was to review the frequency and type of headache syndromes associated with menopause, to review the evidence for specific treatments for headache associated with menopause, and to provide management recommendations and prognostic guidance.
We reviewed both clinic- and population-based studies assessing headache associated with menopause. Headache in menopause is less common than headache at earlier ages but can present a unique challenge. Migraine phenotype predominates, but presentations can vary or be due to secondary causes. Other headache types, such as tension-type headache (TTH) and cluster headache (CH) may also be linked to or altered by hormonal changes. There is a lack of well-defined diagnostic criteria for headache syndromes associated with menopause. Women with surgical menopause often experience a worse course of disease status than those with natural menopause. Hormonal replacement therapy (HRT) often results in worsening of migraine and carries potential for increased cardiovascular and ischemic stroke risk. Estrogen replacement therapy (ERT) in patients with migraine with aura (MA) may increase the risk of ischemic stroke; however, the effect is likely dose-dependent. Some medications used in the prophylaxis of migraine may be useful in ameliorating the vasomotor and mood effects of menopause, including venlafaxine, escitalopram, paroxetine, and gabapentin. Other non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga may also be helpful in reducing headache and/or vasomotor symptoms associated with menopause. The frequency and type of headache associated with menopause is variable, though migraine and TTH are most common. Women may experience a worsening, an improvement, or no change in headache during the menopausal transition. Treatment may be limited by vascular risks or other medical and psychiatric factors. We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga. If HRT is pursued, continuous (rather than cyclical) physiological doses should be used, transdermal route of administration is recommended, and the patient should be counseled on the potential for increased risk of adverse events (AEs). Concomitant use of a progestogen decreases the risk of endometrial hyperplasia with ERT. Biological mechanisms are incompletely understood, and there is a lack of consensus on how to define and classify headache in menopause. Further research to focus on pathophysiology and nuanced management is desired.
综述目的：绝经在许多方面都是改变人生的事件。许多偏头痛女性希望进入更年期状态时偏头痛会停止或改善。这一假设主要基于普遍的大众认知以及医疗界许多人的断言。不幸的是，证据表明情况远非如此。许多女性会向全科医生或头痛专科医生咨询预后和治疗方法。一种自然的本能是控制致病因素，但在某些情况下，这种方法会适得其反，或者对不良事件的担忧超过了进行治疗试验的意愿，因此必须寻求其他策略。我们的目的是回顾与绝经相关的头痛综合征的频率和类型，回顾绝经相关头痛的特定治疗方法的证据，并提供管理建议和预后指导。
最新发现：我们回顾了基于临床和人群的评估绝经相关头痛的研究。绝经后头痛比早年头痛少见，但可能带来独特的挑战。偏头痛表型占主导，但表现可能各异或由继发原因引起。其他头痛类型，如紧张型头痛（TTH）和丛集性头痛（CH）也可能与激素变化有关或受其影响而改变。缺乏针对绝经相关头痛综合征的明确诊断标准。手术绝经的女性疾病状态往往比自然绝经的女性更差。激素替代疗法（HRT）常常导致偏头痛恶化，并有可能增加心血管疾病和缺血性中风的风险。有先兆偏头痛（MA）患者使用雌激素替代疗法（ERT）可能会增加缺血性中风的风险；然而，这种影响可能与剂量有关。一些用于预防偏头痛的药物可能有助于改善绝经的血管舒缩和情绪影响，包括文拉法辛、艾司西酞普兰、帕罗西汀和加巴喷丁。其他非药物策略，如针灸、维生素E、黑升麻、有氧运动和瑜伽，也可能有助于减轻与绝经相关的头痛和/或血管舒缩症状。与绝经相关的头痛频率和类型各不相同，不过偏头痛和紧张型头痛最为常见。女性在绝经过渡期间头痛可能会加重、改善或无变化。治疗可能会受到血管风险或其他医学和精神因素的限制。我们建议使用对偏头痛和血管舒缩症状都有益的药物，包括文拉法辛、艾司西酞普兰、帕罗西汀和加巴喷丁，以及非药物策略，如针灸、维生素E、黑升麻、有氧运动和瑜伽。如果采用HRT，应使用持续（而非周期性）的生理剂量，建议采用经皮给药途径，并应告知患者不良事件（AE）风险增加的可能性。同时使用孕激素可降低ERT引起子宫内膜增生的风险。生物学机制尚未完全了解，对于如何定义和分类绝经后头痛也缺乏共识。需要进一步研究关注病理生理学和细致的管理。
