The safety of acupuncture for migraine prevention during pregnancy.

Relief from migraine attacks may be obtained through non-pharmacological therapy during pregnancy when most drugs are contraindicated. There is accumulating evidence for the efficacy and safety of acupuncture for migraine in the general population but very little to no data on acupuncture during pregnancy. With this retrospective study, we wanted to determine whether an association exists between acupuncture treatment and preterm delivery and side effects of therapy. The initial study group was 68 women with migraine (29.78% with aura and 70.21% without aura), 47 of which responded to a questionnaire on acupuncture safety within 6 weeks of delivery. A so-called Formula Acupuncture was used for all these patients in order to permit comparison. Influence of acupuncture on gestational age at birth was carried out according to number of treatment sessions (more than and fewer than 10) and stratifying the study sample by age group (over and under 30 years) and risk pregnancy. Analysis showed no statistically significant difference in gestational duration between the two groups or an association between the number of acupuncture sessions and preterm delivery. Symptoms during treatment were generally transient or mild. The most common symptoms were relaxation, pain at the insertion sites, mild bleeding, and paresthesia. Our preliminary data indicate that acupuncture may be safe during pregnancy in women with migraine.

Gender-related differences in migraine.

Migraine is considered mostly a woman's complaint, even if it affects also men. Epidemiological data show a higher incidence of the disease in women, starting from puberty throughout life. The sex-related differences of migraine hold clinical relevance too. The frequency, duration, and disability of attacks tend to be higher in women. Because of this, probably, they also consult specialists more frequently and take more prescription drugs than men. Different mechanisms have been evaluated to explain these differences. Hormonal milieu and its modulation of neuronal and vascular reactivity is probably one of the most important aspects. Estrogens and progesterone regulate a host of biological functions through two mechanisms: nongenomic and genomic. They influence several neuromediators and neurotransmitters, and they may cause functional and structural differences in several brain regions, involved in migraine pathogenesis. In addition to their central action, sex hormones exert rapid modulation of vascular tone. The resulting specific sex phenotype should be considered during clinical management and experimental studies.

Migraine during pregnancy and in the puerperium.

Pregnancy can be seen as a positive time for women migraineurs because the elevated estrogen and endogenous opioid levels raise the pain threshold and the stable hormone levels, which no longer fluctuate, eliminate a major trigger factor for the attacks. In a great majority of cases, indeed, migraine symptoms spontaneously improve throughout pregnancy. Generally, migraine without aura (MO) improves better than migraine with aura (MA), which can occur ex novo in pregnancy more frequently than MO. After childbirth, the recurrence rate of migraine attacks increases, especially during the first month; breastfeeding exerts a protective effect against the reappearance of attacks. Migraine and pregnancy share a condition of hypercoagulability; therefore, attention must be paid to the risk of cardiovascular disorders, like venous thromboembolism and ischemic or hemorrhagic strokes. Some of these diseases can be linked to preeclampsia (PE), a serious complication of pregnancy, characterized by hypertension, proteinuria, or other findings of organ failure. This condition is more common in migraineurs compared with non-migraineurs; furthermore, women whose migraines worsen during pregnancy had a 13-fold higher risk of hypertensive disorders than those in which migraine remitted or improved. Pregnancy is generally recognized to exert a beneficial effect on migraine; nonetheless, clinicians should be on the alert for possible cardiovascular complications that appear to be more frequent in this patient population.

Estrogen, migraine, and vascular risk.

Migraine has a predilection for female sex and the course of symptoms is influenced by life stage (presence of menstrual cycle, pregnancy, puerperium, menopause) and use of hormone therapy, such as hormonal contraception and hormone replacement therapy. Hormonal changes figure among common migraine triggers, especially sudden estrogen drop. Moreover, estrogens can modulate neuronal excitability, through serotonin, norepinephrine, dopamine, and endorphin regulation, and they interact with the vascular endothelium of the brain. The risk of vascular disease, and ischemic stroke in particular, is increased in women with migraine with aura (MA), but the link is unclear. One hypothesis posits for a causal association: migraine may cause clinical or subclinical brain lesions following repeated episodes of cortical spreading depression (CSD) and a second hypothesis that may explain the association between migraine and vascular diseases is the presence of common risk factors and comorbidities. Estrogens can play a differential role depending on their action on healthy or damaged endothelium, their endogenous or exogenous origin, and the duration of their treatment. Moreover, platelet activity is increased in migraineurs women, and it is further stimulated by estrogens.This review article describes the course of migraine during various life stages, with a special focus on its hormonal pathogenesis and the associated risk of vascular diseases.

Treating migraine with contraceptives.

At least 18% of women suffers from migraine. Clinically, there are two main forms of migraine: migraine with aura (MA) and migraine without aura (MO) and more than 50% of MO is strongly correlated to the menstrual cycle. The high prevalence of migraine in females, its correlation with the menstrual cycle and with the use of combined hormonal contraceptives (CHCs) suggest that the estrogen drop is implicated in the pathogenesis of the attacks. Although CHCs may trigger or worsen migraine, their correct use may even prevent or reduce some forms of migraine, like estrogen withdrawal headache. Evidence suggested that stable estrogen levels have a positive effect, minimising or eliminating the estrogenic drop. Several contraceptive strategies may act in this way: extended-cycle CHCs, CHCs with shortened hormone-free interval (HFI), progestogen-only contraceptives, CHCs containing new generation estrogens and estrogen supplementation during the HFI.

Acupuncture for pain and pain-related disability in deep infiltrating endometriosis.

Objectives: To evaluate the efficacy of acupuncture in relieving symptoms (dysmenorrhea, dyspareunia, pelvic pain and dyschezia) intensity, improving functional disability, reducing the number of days per months of dysmenorrhea, the frequency and the efficacy of analgesic use in deep infiltrating endometriosis (DIE). The safety profile was also evaluated. Methods: The study sample was 34 patients with DIE; for 2 months (T-2, T-1) the women recorded diary notes on the numbers of days of menstruation, the presence, intensity, and disability related to dysmenorrhea, dyspareunia, pelvic pain, and dyschezia. They then received a total of 15 acupuncture treatments over 6 months (T1-T6; once a week for 12 weeks, then once a month for 3 months). Results: Dysmenorrhea intensity was decreased during treatment. A decrease of at least 50% in number of days of dysmenorrhea, and a decrease in moderate-to-severe disability starting from T1 to T6 was recorded for 58.6% of patients. Dyspareunia intensity steadily decreased starting at T2; the percentage of women with moderate-to-severe disability declined from 73.3% at T-2, to 36.9% at T3, T4, and T5. A decrease in pelvic pain score was noted starting at T1; the percentage of disability decreased from 83.3% at T-2 to 33.3% at T3 and T6. The intensity of dyschezia decreased from T-2 to T3 and T4 and then increased slightly. Analgesic drug use was lower during treatment and its efficacy appeared to be greater. Conclusions: The limitations notwithstanding our study-findings show that acupuncture was safe and effective in reducing pain intensity and symptoms-related disability. Larger-scale studies are needed to compare acupuncture and pharmacotherapy for endometriosis-related pain.

Different aquaporin-4 expression in glioblastoma multiforme patients with and without seizures.

Aquaporin-4 (AQP-4), the most important water channel in the brain, is expressed by astrocyte end feet abutting microvessels. Altered expression levels of AQP-4 and redistribution of the protein throughout the membranes of cells found in glioblastoma multiforme (GBM) lead to development of the edema often found surrounding the tumor mass. Dysregulation of AQP-4 also occurs in hippocampal sclerosis and cortical dysplasia in patients with refractory partial epilepsy. This work reports on analysis of the relationship between AQP-4 expression and the incidence of epileptic seizures in patients with GBM. Immunohistochemical and polymerase chain reaction techniques were used to evaluate AQP-4 in biopsy specimens from 19 patients with GBM, 10 of who had a history of seizures before surgery. AQP-4 mRNA levels were identical in the two groups of patients, but AQP-4 expression was more frequently detected on the GBM membranes from specimens of patients with seizures than from individuals without (10 versus 2, P < 0.001). We conclude that reduced expression of cell surface AQP-4 is characteristic of GBM patients without seizures, likely attributable to a posttranslational mechanism.

New onset headache during delivery and postpartum: Clinical characteristics of a case series.

Introduction: There are abundant studies on headache and migraine in women but few or none about their occurrence during labor, delivery, and postpartum (2 hours after delivery) owing to the low incidence. A headache attack can be debilitating when a woman is trying to manage labor pain. Research at our Women's Headache Center within the Department of Gynecology and Obstetrics has begun to shed light on this potential association. Methods: For the present study 474 women with singleton pregnancy were enrolled. A headache questionnaire was administered at two time points. Headache history was investigated on admission to prenatal care at 36 weeks gestation. The women were followed by a midwife who monitored labor progression and recorded the onset and features of headache pain. During examination before hospital discharge at 3 days post-delivery, the headache questionnaire was reviewed by a headache specialist who differentiated headache type according to International Classification of Headache Disorders (3rd edition) criteria. Results: Data analysis showed that 145/474 women had a history of headache: 65/145 (44.82%) reported a diagnosis of migraine. Eight reported experiencing a probable migraine attack (4 with aura) and one reported probable tension-type headache during labor or postpartum. All nine women who reported migraine/headache attack during labor had no previous history of headache or neurological illness. All had vaginal delivery. No onset of headache pain in patients with a previous history of headache was noted during delivery and postpartum. Discussion: The onset of a headache attack during labor in women who usually do not experience headache suggests other pathogenic mechanisms underlying the attack and merits further study.

Arterial stiffness in normal pregnancy at 11-13 weeks of gestation and risk of late-onset hypertensive disorders of pregnancy.

OBJECTIVE: We evaluated the possible correlation between pulse wave analysis (PWA) parameters measured during the first trimester of pregnancy in normotensive, low-risk women, and the development of hypertensive disorders later in pregnancy. Our hypothesis was that a still asymptomatic increase in arterial stiffness may potentially precede the onset of overt hypertension in pregnancy and that PWA could detect it. METHODS: The study population (n = 1648) was recruited at the time of prenatal screening for chromosomal abnormalities (11-12 weeks of gestation). The radial pressure waveform was obtained with an applanation tonometer (Sphygmocor, Atcor Medical, West Ryde, Australia) on pregnant women in recumbent position. Arterial stiffness was evaluated using arterial PWA. The aortic systolic pressure (aSp), aortic diastolic pressure, and aortic mean pressure, the aortic pulse pressure, the augmentation pressure, and the augmentation index were calculated. The main outcome measure was the development of hypertensive disorders later in pregnancy. RESULTS: The values of aSp (P < 0.0001), aortic diastolic pressure (P < 0.0001), aortic mean pressure (P < 0.0001), aortic pulse pressure (P = 0.0140), and augmentation index-75 (P < 0.0001) measured in the first trimester of pregnancy were significantly higher in the women who later developed hypertensive disorders of pregnancy than in those who remained normotensive. The aSp (sensitivity 72.6%; specificity 59.6%) was found to be the best predictor for the later development of hypertension. CONCLUSION: In normotensive, low-risk pregnant women, PWA may be useful for the early detection of risk for the development of hypertensive disorders of pregnancy.

Menstrual migraine: a review of current and developing pharmacotherapies for women.

INTRODUCTION: Migraine is one of the most common neurological disorders in the general population. It affects 18% of women and 6% of men. In more than 50% of women migraineurs the occurrence of migraine attacks correlates strongly with the perimenstrual period. Menstrual migraine is highly debilitating, less responsive to therapy, and attacks are longer than those not correlated with menses. Menstrual migraine requires accurate evaluation and targeted therapy, that we aim to recommend in this review. AREAS COVERED: This review of the literature provides an overview of currently available pharmacological therapies (especially with triptans, anti-inflammatory drugs, hormonal strategies) and drugs in development (in particular those acting on calcitonin gene-related peptide) for the treatment of acute migraine attacks and the prophylaxis of menstrual migraine. The studies reviewed here were retrieved from the Medline database as of June 2017. EXPERT OPINION: The treatment of menstrual migraine is highly complex. Accurate evaluation of its characteristics is prerequisite to selecting appropriate therapy. An integrated approach involving neurologists and gynecologists is essential for patient management and for continuous updating on new therapies under development.

The use of progestogen-only pill in migraine patients.

Migraine is a debilitating neurovascular disorder which is estimated to affect 18% of women and 6% of men. Two main forms of this neurological disorder must be considered: Migraine without Aura and Migraine with Aura. Migraine without aura often has a strict menstrual relationship: the International Headache Society classification gives criteria for Pure Menstrual Migraine and Menstrually Related Migraine. The higher prevalence of migraine among women suggests that this sex difference probably results from the trigger of fluctuating hormones during the menstrual cycle. Safe and effective contraception is essential for all women of childbearing age, but Combined Oral Contraceptives have been associated with worsening of attacks and cardiovascular risk in these patients. We analyzed characteristics, effects and benefits of progestogen-only pill, a possible alternative for contraception in women with migraine.