Abstract
Introduction
We conducted a questionnaire survey of Japanese women with migraine who presented at neurology and gynecology headache clinics to assess how the frequency and severity of migraine in pre-, peri-, and postmenopausal women changed as compared with what they experienced in their 20s and 30s.
Methods
The study group comprised 171 women with migraine (mean age 48.5) at the time of the survey. They were requested to fill out a self-administered questionnaire.
Results
(1) The current frequency and severity of migraine were claimed to be higher than that in their 20s and 30s. (2) More than 50% of postmenopausal women responded that migraines were currently less frequent than in their 20s and 30s. (3) The largest proportion of postmenopausal women responded that migraine was currently less severe than during any other period.
Conclusions
Our survey demonstrated that there are trends toward fewer migraine attacks and milder symptoms in postmenopausal Japanese women.
Introduction
Migraine is a primary headache characterized by episodic attacks of severe headache (1). In women, fluctuations in female hormone levels associated with monthly menstrual cycles and various stages of life, such as pregnancy, parturition, nursing, and menopause, are known to affect the frequency and severity of migraine.
Climacteric women have menopause, which is caused by a complex series of hormonal changes, resulting in and including a dramatic reduction in the production of estrogen. Menopause has been considered to decrease the frequency and intensity of migraine (2). However, symptoms of migraine have also been reported to transiently worsen during perimenopause (3). To our knowledge, however, the association between migraine and menopause remains to be fully investigated in Japan.
As a pilot study, we designed the present study to assess changes in the frequency and severity of migraine attacks in Japanese climacteric women during menopause and perimenopause.
Methods
The study group comprised women aged 40 to 60 years at the time of the survey. All participants presented at one of the following four facilities during the six months from January through June 2012: the Department of Neurology, Kohnan Hospital (Kobe City, Hyogo), Tatsuoka Neurology Clinic (Kyoko City, Kyoto), Makita Obstetrics and Gynecology Clinic (Niiza City, Saitama), and the Department of Obstetrics and Gynecology, Rottuko Island Hospital (Kobe City, Hyogo). Migraine was clinically diagnosed according to the International Classification of Headache Disorders, second edition (ICHD-II) (1).
All patients received an explanation about the main points of the study from their physicians at the participating centers and gave informed consent to participate. They were then requested to fill out a self-administered questionnaire designed by us.
The survey was approved by an ethics committee. To protect personal information and preserve anonymity, the participants’ names and identification numbers at each center were not filled out. Shigekazu Kitamura, one of the coauthors, centrally managed all data obtained from each participating center and performed data analysis.
A summary of the questions included in the questionnaire is presented below.
Question 1: Age at the time of the survey. Question 2: Age at first menstruation. Question 3: The current status of menstruation: Premenopause: Regular menstrual cycles. Perimenopause: Menstruation occurs, but the cycles are irregular. Postmenopause: Menstruation has not occurred for more than one year; menopause has already begun. Unknown: Menstruation no longer occurs because of hysterectomy. However, the status of ovarian hormones is unclear. Question 4: Age at the initial onset of headache. Question 5: Current frequency of headache: The number of episodes per month is recorded. Question 6: Current severity of headache: recorded on a visual analog scale (VAS). Question 7: In menstruating women, the presence or absence of headache during menstruation. Question 8: Comparison of the current frequency of migraine attacks with that in their 20s and in their 30s. Choose the best possible answer: At present, migraines are (a) less frequent, (b) unchanged, or (c) more frequent. Question 9: Comparison of the current severity of migraine attacks with that in their 20s and in their 30s. Choose the best possible answer: At present, migraines are (a) less severe, (b) unchanged, or (c) more severe.
Exclusion criteria were the presence of other neurological conditions besides headaches or secondary headache; we also excluded individuals who did not answer all of the questions. However, women who had their first migraine attack in their 30s did not have to respond to questions inquiring about the status of migraine in their 20s.
A total of 171 participants were included in the final analysis. The data were statistically analyzed with SPSS (Statistics Premium Grad Pack version 22 for Windows, IBM, Chicago, IL, USA). Cochran-Mantel-Haenszel tests were used to evaluate the statistical significance of differences among three groups or ages. P values of less than 0.05 were considered to indicate statistical significance.
Results
Clinical characteristics of menstruation and migraine in survey participants
Demographic characteristics of 171 women with migraine.
ICHD-II: International Classification of Headache Disorders, second edition.
The clinical diagnosis of migraine was migraine with aura in 10 women (6.2%), migraine without aura in 161 (93.8%), and menstrual-related migraine in 109 (109/161: 67.7% excluding migraine with aura).
Among the 130 currently menstruating individuals, 76 (84.4%) of the 90 women in the preM group and 33 (82.5%) of the 40 women in the periM group had migraine attacks during menstruation.
Current frequency of migraine attacks as compared with status when participants were in their 20s and 30s
Figure 1(a) shows whether migraine attacks were currently ‘less frequent,’ ‘unchanged,’ or ‘more frequent’ as compared with the status during their 20s and 30s.
(a) The frequency of current migraine attacks in comparison with the status in participants’ 20s and 30s. (b) The severity of current migraine attacks in comparison with the status in participants’ 20s and 30s.
‘More frequent’ was the most common response as compared with when the participants were in their 20s and 30s. However, there were no significant differences in the rates of ‘more frequent’ as compared with that in their 20s and 30s.
Frequency of current migraine attacks according to menstruation status
Figure 2(a) shows the results obtained by comparing the current frequency of migraine with that when the participants were in their 20s and 30s, according to whether the individual belonged to the preM group, periM group, or postM group. The largest proportions of the preM and periM groups thus responded that migraines were ‘more frequent’ than previously. In contrast, in the postM group, more than 50% of individuals responded that migraines were currently ‘less frequent’ than in their 20s and 30s. The frequency of migraine was significantly lower in the postM group than in the preM and periM groups in their 30s. However, it was significantly lower in the postM group than in the preM group in their 20s, and there were no significant differences as compared with the periM group.
(a) The frequency of current migraine attacks according to menstruation status. (b) The severity of current migraine attacks according to menstruation status. PreM: premenopause; PostM: postmenopause; PeriM: perimenopause.
Severity of current migraine attacks as compared with status when participants were in their 20s and 30s
Figure 1(b) shows the proportions of participants who responded that migraine was currently ‘less severe,’ ‘unchanged,’ or ‘more severe’ as compared with the severity in their 20s and 30s. ‘More severe’ was the most common response as compared with when the women were in their 20s and 30s. However, there were no significant differences in the rates of ‘more severe’ as compared with when the participants were in their 20s and 30s.
Severity of current migraine attacks according to menstruation status
Figure 2(b) compares the current severity of migraine with that in their 20s and 30s, according to whether the participants belonged to the preM group, periM group, or postM group. More than 40% of the preM group responded that migraine was ‘more severe’ at present than in their 20s and 30s. In the periM group, the proportions of patients who responded that the current severity of migraine was higher than that in their 20s and in their 30s were 40.0% and 32.5%, respectively. In contrast, the largest proportion of menopausal women responded that the migraine was currently ‘less severe’ than during any of the other periods. The severity of migraine was significantly less severe in the postM group than in the preM and periM groups.
Discussion
This is the first study to assess changes in the incidence and severity of migraine during menopause and periM in Japanese women with migraine as compared with when they were young. Our study indicated that more than 50% of postM women responded that both the frequency and severity of migraine improved as compared with the frequency and severity in their 20s and in their 30s.
To our knowledge, the relation between natural menopause and migraine headaches was first reported by Whitty and Hockaday (4). One study in the 1970s and one in the 1980s assessed the influence of natural menopause on migraine (5,6). Since the report by Neri et al. (7), this topic has been studied in relatively large numbers of women. The study showed that symptoms improved after menopause in about two-thirds of women with migraine. Subsequently, the results of relatively large studies were reported by some investigators (8–12). Overall, the findings suggested that the frequency and severity of migraine in women tend to improve after natural menopause.
Our improvement rates were slightly higher than those in previous studies. On the other hand, our results indicate that menopause does not immediately lead to the improvement of migraine in Japanese women.
Our analysis also showed that migraine was significantly more frequent and severe in the periM and preM groups than in the postM group.
However, our study has the limitation that we had to depend on the participants’ memory of past events. Therefore, the possibility of recall bias cannot be completely eliminated. Long-term population-based studies following up women from preM to postM should be performed and may provide clearer answers to many open questions. Such studies are difficult to perform in Japan. However, it is hoped that continued collaboration between gynecologists and neurologists will provide a better understanding of the problem.
Conclusions
We believe that the effective management of migraine in women before and after menopause requires close cooperation between neurologists and gynecologists.
Clinical implications
The frequency and severity of migraine in premenopausal and perimenopausal Japanese women tended to increase as compared with what they experienced when they were younger. There are trends toward fewer migraine attacks and milder symptoms in postmenopausal Japanese women. On the other hand, the frequency and severity of migraine increased in an appreciable number of menopausal Japanese women. We consider that the effective management of migraine in climacteric women requires close cooperation between neurologists and gynecologists.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.