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June 1997

Calming the Hell in Your Head
By Nancy Monson

Migraines are three times more common in women than men. Here's the latest on treatment and prevention

Like 23 million other women, I am what doctors call a migraineur. A couple of times each month, I’m felled by debilitating headaches that send me to bed for a day or more, unable to think, read, write or even watch television.

Until recently, my best remedies were ice packs, hot showers and a variety of prescription and over-the-counter pain pills. Sometimes the remedies worked; most often they didn’t. And frequently I couldn’t even keep the pain pills down, thanks to the nausea that usually accompanies a migraine.

Now, as soon as I feel the stirrings of a migraine, I have another option. I pop a newly approved pill, Imitrex, which works directly on the brain chemical that triggers migraines. The pain is gone within the hour.

Once considered a unique species of headache, migraines are now seen as one end of a spectrum of headache pain. Chronic headaches seem to involve a glitch—probably inherited—in the way the brain handles serotonin, a neurotransmitter that influences mood and sleep and regulates constriction and dilation of blood vessels. One theory suggests that an electrical change in the brain produces a surge in serotonin, which narrows the blood vessels; serotonin then leaks into surrounding tissues, dilating the same blood vessels and irritating nerve endings. Result: throbbing head pain.

Still, a genetic propensity does not a headache make. Over- or undersleeping, missing a meal, getting too much sun, a change in barometric pressure, eating foods containing nitrites (like bacon) or amines (aged cheese or red wine) and the letdown after a stressful event are all common triggers for the serotonin disturbance that ends in head pain, nausea, light sensitivity, numbness of extremities, or any combination of these symptoms.

The biggest trigger in women, however—and an explanation for why migraines are three times more common in women than men—is the dramatic drop in estrogen that occurs  just before menstruation. Fluctuating estrogen levels are probably why a third of migraineurs have their first migraine attack around puberty, and 70 percent get predictable and often difficult to treat headaches between ovulation and the end of their cycles. It's also why women in their forties, who are subject to several years of declining estrogen levels, often suffer from more frequent and intense migraines prior to menopause.

About a third of migraine sufferers also say their headaches get worse when they take the Pill—presumably because they’re still susceptible to the drop in estrogen that occurs before their periods. Another third of Pill-takers get better, and the remaining third report no change.

Three quarters of women find temporary relief from migraines during the last six months of pregnancy, when estrogen levels rise and stay steady. And 70 percent of migraineurs become migraine-free after menopause, when estrogen levels fall and stay low.

New Drug Treatments
Women don't need to wait until menopause to find relief from migraines, but effective treatment requires experimentation and patience. "Migraine isn’t a one-drug-cures-all disorder," explains Richard Lipton, M.D., codirector of the headache unit at New York City’s Montefiore Medical Center. "There are different types and degrees of migraine, and not everyone responds in the same way to every drug." 

A new generation of medications that act directly on the serotonin system makes treatment easier than ever before. Here, an update on the options:

Imitrex. Available as an injection since 1993, this drug was recently approved in pill form and may soon become available in a quick-acting nasal spray. By mimicking the action of serotonin in the brain, Imitrex has revolutionized migraine treatment (it has been a miracle for me). Seventy to 80 percent of migraine sufferers who take the pill find their headaches ease within one to four hours; with the injection, relief is about 30 to 60 minutes away. If a migraine recurs after a few hours, as it does for 10 to 15 percent of sufferers, it's safe to take a second dose.

The downside: This drug is a potent blood vessel constrictor and can be dangerous if taken by someone with heart disease. In others, it can cause mild side effects such as tingling, a sensation of pressure or heaviness, drowsiness or dizziness. It's also expensive ($9 to $12 per pill; $35 to $40 per injection).

Other serotonin imitators. Zomig, Maxalt and naratriptan—all of which also mimic the effects of serotonin—are all slated for Food and Drug Administration approval , and five similar drugs are in development. (Zomig may be approved as early as this year.) It's hoped that one or more of these will work faster or offer longer-lasting pain relief than Imitrex, says Alan Rapoport, M.D., codirector of the New England Center for Headache in Stamford, Connecticut. Competition among these drugs should also bring prices down.

DHE45. This self-injectable drug constricts blood vessels and also helps regulate serotonin levels, relieving migraine pain in about 80 percent of sufferers. It may take 15 or so minutes longer than Imitrex does to stop pain, and the injection is more painful, but migraines are less likely to recur within a few hours. A quick-acting nasal spray is likely to be released this year.

The disadvantage: When injected, DHE45 can cause severe stomach upset, so many doctors prescribe it with an antinausea drug. Cost: $15 per dose.

Lidocaine. When applied with a Q-Tip in the nasal passages nearest the pain, this anesthetic works quickly—within about five minutes—for about half of migraineurs, reducing pain as well as nausea and sensitivity to light. Lidocaine has few side effects and is inexpensive (a $15 bottle will "last you a lifetime," says one pharmacist).

The disadvantages: Headaches recur for about half of sufferers within an hour. While it's safe to redose lidocaine, it may be best as a stopgap until another drug kicks in, says Dr. Rapoport.

Not every migraine needs to be treated with a big gun like Imitrex, says Stephen D. Silberstein, M.D., codirector of the Comprehensive Headache Center at Germantown Hospital and Medical Center in Pennsylvania. Prescription drugs such as Midrin, Norgesic Forte, Fiorinal, Fioricet and Wygraine have been around for years and can be effective and inexpensive choices. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or ketoprofen—albeit at much larger doses than recommended for nonprescription use (up to 550 milligrams per day of naproxen, for instance)—are particularly good for treating menstrual migraines.

Home remedies can limit your need for medication and, by relaxing you, even speed pain relief. Some women obtain relief from heat or hot showers, ice packs, head massage, putting their hands on a warm pad to draw blood away from the brain, or practicing visual imagery or relaxation techniques. Biofeedback in particular gets high marks: "It's the most effective nondrug technique," says Frederick Freitag, D.O., associate director of the Diamond Headache Clinic in Chicago, "but it's underused because you have to commit to practicing it 20 minutes twice a day." It takes up to 10 sessions to master the technique, he says, and the cost of training (about $500) may not be covered by insurance.

Changing your diet by eliminating trigger foods and adding vitamins and minerals is another strategy to prevent or reduce pain.  Preliminary research conducted by Alexander Mauskop, M.D., director of the New York Headache Center in Manhattan, indicates that about half of migraine sufferers are deficient in the mineral magnesium. An intravenous infusion of magnesium during an attack often works within minutes, and relief  lasts for 24 hours. While studies to confirm magnesium's value are ongoing, and current formulations of oral magnesium aren't absorbed well by the body, experts say it's safe to take 400 to 600 milligrams of the mineral daily. Research also suggests that 100 to 200 milligrams per day of riboflavin (vitamin B2) can reduce migraine intensity for some people. It may take one to two months to see an effect with supplements.

Fat may prove to be another factor in migraines. In the first study of its kind, researchers at Loma Linda University in California found that patients who ate 20 or fewer grams of fat per day for 12 weeks (about 10 percent of total calorie intake) decreased the frequency of their migraines by 71 percent, intensity by 66 percent, duration by 74 percent and medication intake by 72 percent. Says lead researcher Zuzana Bic, M.D., "A restrictive diet may work because it prevents fat in the bloodstream from damaging platelets, which can lead to the serotonin loss that precipitates migraines."

Stopping Migraines Before They Start
If you get more than three headaches a month, doctors may suggest taking drugs every day to prevent them. Among the options:

Try taking ibuprofen or another anti-inflammatory each day for a week or more before and during your period to help prevent menstrual migraines. These drugs stop the release of prostaglandins—compounds that are produced as the uterine lining is shed each month—that cause pain and dilate blood vessels. On the downside, high doses of NSAIDs can cause stomach upset and, with frequent use, even ulcers.

Heart disease drugs such as Inderal and Calan help to regulate blood vessel activity, thus preventing attacks in a significant number of migraineurs. Side effects include fatigue, constipation, heartburn and low blood pressure.

Two categories of antidepressants may help to prevent migraines when taken daily: tricyclics such as Elavil, and selective serotonin reuptake inhibitors (SSRIs) such as Prozac. Tricyclics can cause dry mouth, constipation, tiredness and weight gain. The SSRIs have fewer side effects but don’t work as well.

The epilepsy drug Depakote is the newest preventive treatment and has been shown to reduce migraine episodes for half of the people who try it. Depakote has some nasty side effects, however, such as nausea, diarrhea, weight gain and hair loss.

A preliminary study published in the journal Neurology this year reports that bromocriptine, a drug that mimics the actions of the brain chemical dopamine, decreased menstrual migraine pain for 72 percent of women when combined with other therapies that aren’t effective alone. The medication may cause nausea and lightheadedness.

 

 

 

 

 

March 1997

The Best News Yet About the Pill!
By Nancy Monson

The latest studies and the best experts conclude it's safer than ever

How much do you really know about the birth control pill? If you're on it now, are you sure you're taking it correctly?

Ten million American women currently use the Pill, and eight out of 10 will use it at some point in their reproductive lives, making it the most popular reversible method of birth control in the United States. Yet recent studies show that we're less clear than we should be on how oral contraceptives work, how best to take them and how to weight their risks and benefits. Answers to these questions aren't easy to come by, since drug labeling is complicated and sessions with doctors are too brief. A recent onslaught of new research and the occasional scary headline add to the confusion.

Because so many women are misinformed about the Pill, GLAMOUR asked the nation's top contraception experts for answers to your most common and perplexing Pill questions.

1. How long can I safely stay on the Pill?
As long as you’re in good health and don’t smoke, you can use oral contraceptives without interruption from your teens until menopause. There are no added health risks associated with long-term Pill use, nor is there any evidence that you need to take breaks from the Pill.

In truth, the longer you stay on the Pill, the better it is for your health: Your risks of uterine and ovarian cancer decline significantly, and the benefits persist for at least 15 years after you stop taking it. What’s more, aside from having children (or having your ovaries surgically removed), the Pill is the only known way to significantly reduce the risk of ovarian cancer—a deadly disease for which there is no reliable screening test.

2. Will taking the Pill make it harder for me to get pregnant in the future?
It won’t hurt your chances—and it may help them. Oral contraceptives protect your future fertility by reducing your risk of pelvic inflammatory disease (a complication of untreated sexually transmitted diseases), ectopic pregnancy (a potentially life-threatening condition in which an embryo implants and grows outside the uterus, usually in a fallopian tube) and endometriosis (a condition in which uterine tissue grows in the pelvic cavity).

3. How long should I wait after going off the Pill before I start trying to get pregnant?
You don’t have to wait at all—the drug is excreted from the body within a few days. And there’s no evidence that getting pregnant soon after stopping Pill use, or even while you’re on the Pill, has a negative effect on a fetus. The reason some doctors advise waiting a month or more is so you’ll have a period, which will make it easier for your obstetrician to figure out your due date.

4. When I was on the Pill 10 years ago, I gained weight, felt nauseated and had spotting. Would that happen if I went on it again?
You’d probably experience fewer side effects now because the Pill formulations in widespread use today contain less estrogen and progestin than oral contraceptives prescribed a decade ago. Still, nausea and irregular bleeding are common side effects of the Pill—especially during the first three cycles, when your body is adjusting to the synthetic hormones.

To counteract nausea, take your Pill before going to bed, since you're less likely to notice an upset stomach while asleep, or with dinner or breakfast. You're also less likely to have spotting if you take the Pill at the same hour each day and are careful not to skip any doses.

As for weight gain, most experts contend that excess pounds are related more to aging, diet and lifestyle than to Pill use. Studies have shown that whether women are on the Pill or off, they gain approximately the same small amount of weight as they age--about four pounds over five years.

You know your body best, however—if you are one of the few women who truly has gained weight due to the Pill, or if you suffer other side effects that last beyond three months, ask your doctor about switching to a Pill brand that contains a different form of progestin or lower doses of both hormones.

5. I’m not lubricating as much as I used to, and my sexual desire has lessened. Could this be because of the Pill?
Decreased vaginal lubrication can occur while you’re on the Pill, but it’s not a common problem. As a temporary solution, try using a water-based lubricant such as Astroglide (available in drugstores). Be sure to give yourself enough time to become aroused before attempting intercourse.

There are very few published studies on the effects of the Pill on sexuality—which is surprising given the millions of women who use it. Some doctors say that women on the Pill experience more arousal because it frees them from pregnancy worries, reduces menstrual flow and eases period pain. But desire is at least partially fueled by testosterone, and the Pill may, in some women, reduce levels of this hormone.

Insist that your doctor take seriously complaints of reduced libido or lessened ability to reach orgasm. If there is nothing else in your life that could be responsible for the change, talk to your physician about switching to a different Pill brand or using a different contraceptive method for three to six months to see if that helps.

6. I’ve been depressed for several months. Is it because I'm taking oral contraceptives? Can they cause other mood changes?
In general, moods like depression and irritability improve with Pill use because you receive a steady, low dose of estrogen and progestin—hormones that can wreak havoc with moods when they fluctuate too much. But a reaction to the type of estrogen or progestin used in a specific brand, or a Pill-induced deficiency of vitamin B6—a problem with older, higher-dose pills—may have the opposite effect in some individuals.

"I had one patient who went on the Pill right after giving birth and thought she had a really bad case of postpartum depression for seven years," recalls Robert A. Hatcher, M.D., professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. "She never thought the Pill might be to blame for the way she felt, and no doctor ever singled it out either. When I switched her from a combination oral contraceptive to a low-dose progestin-only Pill, the depression vanished."

Many factors influence depression, but if you and your doctor suspect the Pill may be exacerbating feelings of sadness and lethargy, it won't hurt to switch to another formulation while you're exploring other causes. In some cases, your doctor may also recommend that you take 20 milligrams of vitamin B6 daily.

7.Since I’m not ovulating while on the Pill, why do I still get PMS?
Premenstrual syndrome is thought to be triggered—at least in part—by the drop-off in estrogen and progestin that occurs right before your period. This hormonal shift happens even when you're on the Pill, but the drop is less dramatic—that's why oral contraceptives tend to lessen PMS symptoms in most users.

PMS is poorly understood, however, and other hormones besides estrogen and progestin, as well as nonhormonal factors, are also likely to be involved, Switching brands—especially to a progestin-only Pill—may help to ease your symptoms.

8.Does the Pill raise my risk of breast cancer?
The latest study to examine this question offers reassuring news. Last year an international group of researchers pooled and  reanalyzed data from nearly 154,000 women who were subjects of previous Pill trials. As reported in the journals The Lancet and Contraception, there was no increase in the rate of breast cancer among women who had used the Pill 10 to 20 years before. (Data beyond 20 years isn't available, but experts predict similar results.) These findings held true for all women, regardless of family history, the number of years they'd taken the Pill, and whether they'd taken high- or low-dose pills, as well as many other factors.

The study did find a slightly increased risk of being diagnosed with the disease among women currently taking the Pill and those who'd quit less than 10 years before. (In women ages 25 to 29, for instance, 4.3 cancers per 10,000 were detected among Pill users, compared with 3.5 cancers among women not on the Pill.) But since long-term use doesn't appear to affect the risk of cancer in later years, when breast cancer is more common, researchers speculate that young Pill users have more frequent breast exams than nonusers—suggesting that cancers are simply being detected earlier. Also reassuring was the finding that Pill users of all ages who developed cancer tended to have localized—and thus more easily treated—tumors.

The bottom line: Breast cancer is extremely rare among young women, and using the Pill when you're young does not appear to increase your risk of developing the disease later in life. In fact, some researchers predict that oral contraceptive use may turn out to be protective against breast cancer after menopause, when women are most vulnerable to the disease.

9.I recently read that certain types of oral contraceptives can increase your risk of blood clots. Which types and how big is the risk?
Let’s put things in perspective: Among pregnant women, about 60 out of 100,000 will develop blood clots in the leg or lungs. Among healthy women who don't use the Pill, the rate is about four out of 100,000.

Compared with the risk of clots during pregnancy, the risk of developing them from Pill use is relatively low. Data from European studies released last year showed that pills containing low doses of so-called older progestins, levonorgestrel and norethindrone, each year caused about 10 to 15 women per 100,000 to experience blood clots. Concerns arose, however, when the studies appeared to show that pills containing newer progestins, desogestrel and gestodene, were associated with 20 to 30 cases per years. (Desogestrel pills go by the brand names Desogen and Ortho-Cept; gestodene pills aren’t sold in the U.S.)

This apparent doubling of risk frightened many women. However, both the Food and Drug Administration and the American College of Obstetricians and Gynecologists have examined the studies carefully and concluded that the actual risk of blood clots associated with newer progestins is negligible. Both groups advised that women using  Desogen and Ortho-Cept should keep on using them; there was no reason to switch to another brand.

10.Does the Pill increase the risk of other types of cardiovascular disease, like stroke?
Not unless you are over 35 and smoke cigarettes, or have some other risk factor for heart disease or stroke (such as obesity, high blood pressure and/or high cholesterol). For otherwise healthy women, using the Pill seems to have no effect on the health of their hearts and arteries—and may even lower their risk of cardiovascular disease.

Past studies did find an increase in strokes among women taking high-dose pills (those containing 80 to 100 micrograms of estrogen). But a recent study—the first to look at pills containing less than 50 micrograms of estrogen—published in The New England Journal of Medicine reported that low-dose pills do not increase strokes. Also, one of the same European studies that implicated the newer progestins as causing more blood clots ended prematurely, just as evidence began to suggest that this type of Pill may actually protect users against heart attacks.

11. What does it mean if I skip a period while I’m taking the Pill?
Probably nothing. Low-dose pills can change bleeding patterns. Progestin thins the uterine lining so there’s less to be shed during a menstrual period. In fact, some women on the Pill may routinely miss periods—there’s no harm to that—or may have a period consisting of only a few spots of blood.

If you skip one period and you’ve been taking the Pill as you should—i.e., every day at the same time—you needn't worry. But if you skip two periods or you haven’t been taking the Pill consistently, use a home pregnancy test or call your doctor.

12. Are there any drugs that lessen the effectiveness of the Pill?
Several prescription drugs appear to decrease the Pill's effectiveness. Antiseizure medications, such as carbamazepine and phenytoin; rifampin, the drug used to treat tuberculosis; and griseofulvin, an antifungal prescribed for certain skin and nail infections, are most likely to interfere with the Pill's ability to prevent ovulation and thus pregnancy. Women who take these medications should use a backup method. Many women have heard that a number of antibiotics interfere with oral contraceptives, but experts say there is no proven reason to worry about such an interaction. Even so, some doctors still advise using a backup contraceptive while on antibiotics—just to be safe.

13. I just broke up with my boyfriend and I want to stop taking the Pill. Is it unhealthy to stop and start Pill use?
No, but you may be putting yourself at undue risk of pregnancy if you start a new sexual relationship before you’ve taken seven days of birth control pills. A recent study found that as many as two-thirds of the one million unplanned pregnancies in the United States each year can be traced to going off the Pill without immediately adopting another method. The other problem with stopping Pill use is that you miss out on its noncontraceptive benefits, such as lighter periods, regular cycles, and less menstrual cramping.

14 .How does my doctor choose the right Pill brand for me?
There are 30-odd Pill formulations on the market today. The low-dose pills (those that contain less than 50 micrograms of estrogen) are quite similar, and most women can take any one of them. But women who experience troublesome side effects, or those who have diabetes, acne or excess hair growth, may do better with one formulation over another.

Most doctors prescribe just one or two favorite brands—often the ones that have been most aggressively marketed to them, or those their patients have been satisfied with. Ask your doctor for the least expensive brand or even a generic Pill—and don't forget to ask for free samples.

 

Copyright Nancy Monson

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