| The World Headache Alliance (WHA) and the
International Bureau for Epilepsy have joined to raise awareness
of women's issues in the treatment of migraine and epilepsy, two
disorders that have long carried a stigma.
Babill Stray-Pedersen, MD, professor of gynecology at the
National Hospital in Oslo, said at a news briefing during the
European Federation of Neurological Societies (EFNS) conference in
Seville, Spain, this fall that, although migraine and epilepsy are
not medically related, both are neurological diseases that have
important consequences throughout the lives of the women who have
them, and both may call for a management approach different from
that used with men.
"The hormonal fluctuations occurring at onset of
menstruation, during pregnancy, and during menopause as well as
the issues surrounding the use of oral contraception and hormone
replacement therapy have an important impact on the life and
management of patients with migraine and epilepsy," she said.
Other speakers addressed only migraine. Valerie South,
coordinator of the WHA, based in Oakville, Ontario, explained that
the group was formed a year ago to improve the quality of life of
patients with headache. Now 26 patient organizations in 18
countries represent about 60,000 women, she said.
"Women's issues are too often ignored by clinicians, but
they need to be taken into account if we are to improve the
quality of life of women with migraine," South said, adding
that WHA is working with the International Headache Society (IHS)
to develop educational programs for family physicians.
Jay Rosenberg, MD, a board member of the American Academy of
Neurology, cochairs an international consortium on headache that
represents US and European medical organizations, including IHS
and EFNS. He said this group, the Headache Consortium for
Guideline Development for Primary Care in the Management of
Headache, is developing guidelines for primary care physicians to
improve the management of migraine and other types of headaches.
The guidelines, which are to be issued next year, are designed to
translate evidence-based medicine into practice guidelines.
Worldwide, 240 million people suffer an estimated 1.4 billion
attacks of migraine each year, with the prevalence varying by
country, according to the WHA. Migraine affects three times as
many women as men.
"For the past 100 years, migraine has been thought of as
an imagined disorder and as only a woman's problem," said
South. "Physicians believed women were stressed out from
taking care of children and from lack of ability to cope, but
recent research has underscored the fact that migraine is a real
biological problem."
Stephen Silberstein, MD, director of the Jefferson Headache
Clinic and professor of neurology at Thomas Jefferson University
in Philadelphia, who is cochair of the international headache
consortium, said, "The level of knowledge of how migraine
affects women is very low in both the United States and
Europe." He estimated that half of all US and European
physicians do not believe that migraine is a real disease.
Silberstein said even some gynecologists regard migraine as a
"trivial issue," but that it represents a "major
medical condition, otherwise I would not have devoted my life to
treating it."
Rosenberg suggested that the perception of migraine as a
disease that is not real "reflects European rather than
American thinking." He said primary care physicians tend to
treat migraine in a "reactive" way, rather than develop
an overall management strategy. And he added that "one key
issue is that patients tend to self-medicate."
According to Seymour Diamond, MD, executive chair of the
National Headache Foundation and director of the Diamond Headache
Clinic, both in Chicago, little is taught about migraine in US
medical schools, there are few specialized clinics, the perception
remains that the condition is emotional and psychological, the
primary seekers of help are women, and there are few options for
treatment.
Michael Ferrari, MD, professor of neurology at Leiden
University Medical Center in the Netherlands, said it is
surprising how many primary care physicians and even neurologists
in Europe still think that "migraine is just something for
hysterical females."
Ferrari, who is conducting research into the genetics of
migraine, said, "Ten years ago, if you asked physicians if
migraine was a real disease, about 70% thought it was not. Now,
probably about 40% of physicians think it is not a real disease.
There is still a stigma. Only by identifying the real cause of a
disease, especially when it is genetic, will physicians start
believing that it is real."
Newer Migraine Therapies
With international research on migraine
leading to the development of the class of drugs known as triptans,
serotonin and 1B/1D agonists, the future may hold relief for more
women—as well as men—who experience these headaches.
"Clinical studies with the triptans have burgeoned
throughout Europe and the United States," reported Andrew
Dowson, MD, director of the headache clinic at Kings College
Hospital in London, "with clinical trials going on at a huge
pace over the last 5 years. In most countries, sumatriptan has
become the 'gold standard' for this class of drugs, and now there
are some high-quality comparison studies with the newer triptans."
The drugs sumatriptan, zolmitriptan, and naratriptan have been
approved by the European Commission, and rizatriptan is expected
to be approved soon. Eletriptan is in phase 3 clinical trials,
studies on almotriptan are starting, and other triptans are in the
research pipeline.
Dowson presented new data that compared eletriptan at different
doses with sumatriptan. The findings showed that eletriptan at 20
mg, 40 mg, and 80 mg was at least as effective as sumitriptan,
while at the 80-mg dose, eletriptan was more effective. Although
more patients experienced adverse effects at the higher dose, he
said 88% reported that these effects, such as tingling, were
acceptable and indicated they would use the treatment again.
Lainez said all the triptan drugs have the same mechanism of
action and have become first-line treatment for migraine.
"Results of clinical research show these drugs do not differ
by more than 5% to 10% in regard to efficacy and safety," he
said, adding, "it is important to have a choice of drugs in
the treatment of migraine. It may well be that small differences
in the triptans, such as differences in absorption or half-life or
plasma concentration, may enable physicians to choose different
drug treatments for different patients."
Leiden University's Ferrari said neurologists are developing
better guidelines for conducting clinical trials on migraine
through the IHS. He said the new edition of the guidelines is
stricter: the end point is not merely reduction of pain but
elimination of pain.
Ferrari said he hopes that through research into the basic
mechanism and genetics of migraine, it will become possible to
determine a target for prophylaxis rather than acute treatment.
"Triptans are the first major step forward in the treatment
of migraine, but they are not the optimal treatment," he
said. "One would prefer to have a treatment that prevents
migraine attacks from occurring."
—by Pat Phillips, JAMA
contributor
(JAMA. 1998;280:1975-1976)
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