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Diagnosing and Managing Hormonally Associated Migraine Companion Guide

The presentation companion guide is designed to provide the learner with additional information regarding menstrual migraine and relevant resource links.

Women are subject to increased prevalence of migraine compared to men.¹ Sex hormones, such as 17-beta estradiol (estradiol) contribute to diverse and powerful effects in the brain, including actions on neurons, glia, and the vasculature.² As circulating serum estradiol levels rise and fall during the normal ovarian cycle, alterations in the physiology of the female brain may result. When estradiol levels change dramatically, as during puberty, postpartum or menopause, the central nervous system may also be affected. Changes that occur because of fluctuations in serum estrogen levels are potentially relevant to neurological disorders because symptoms often vary with the time of the ovarian cycle. Moreover, neurological disorders (eg, seizures and migraine) often increase in frequency in women when estradiol levels change. Research thus far has attributed a sudden decrease in circulating estradiol levels as the provocateur of menstrual migraine.^1,2

The fall in circulating estradiol secondarily impacts serotonin regulation. Monoamine oxidase A (MAO-A) is a key regulator of serotonin metabolism.³ When estradiol levels fall, MAO-A increases. This effect leads to a reduction in 5-HT concentration and serotonin synthesis is reduced, as are the number of serotonin receptors. These changes appear to contribute to cortical excitability, even in women with migraine without aura.⁴ It is clear that a drop in circulating estradiol may be ultimately responsible for initiating a sequence of events that leads to migraine without aura in women either close to the onset of their menses or at other times during the menstrual cycle.

The International Headache Society offers a website for their second edition of Classification of Headache Disorders (ICHD-II). The classification criteria begins with the headache phenotype and further differentiates each primary headache to multiple subtypes based on reported evidence of clinical features that aid in accurate differential diagnosis.⁵

Menstrual migraine is now included under migraine without aura (1.1) in the appendix and subtypes include⁵:

• Pure menstrual migraine without aura
  • Diagnostic criteria:
    • Attacks, in a menstruating woman, fulfilling criteria for 1.1 Migraine without aura
    • Attacks occur exclusively on day 1±2 (ie, days -2 to +3) of menstruation in at least two out of three menstrual cycles and at no other times of the cycle
  • Notes:
    • The first day of menstruation is day 1 and the preceding day is day -1; there is no day 0
    • For the purposes of this classification, menstruation is considered to be endometrial bleeding resulting from either the normal menstrual cycle or from the withdrawal of exogenous progestogens, as in the case of combined oral contraceptives and cyclical hormone replacement therapy
• Menstrual-related migraine without aura
  • Diagnostic criteria:
    • Attacks, in a menstruating woman, fulfilling criteria for 1.1 Migraine without aura
    • Attacks occur on day 1±2 (ie, days -2 to +3)¹ of menstruation² in at least two out of three menstrual cycles and additionally at other times of the cycle
  • Notes:
    • The first day of menstruation is day 1 and the preceding day is day -1; there is no day 0
    • For the purposes of this classification, menstruation is considered to be endometrial bleeding resulting from either the normal menstrual cycle or from the withdrawal of exogenous progestogens, as in the case of combined oral contraceptives and cyclical hormone replacement therapy

In response to the new classification system, new International Classification of Disease codes (ICD-9-CM) were updated by the American Headache Society’s Medical Economics Committee under the initial encouragement of Dr. Joel Saper and continued guidance of Dr. Steven Silberstein.⁵ The committee’s recommendations were accepted by the National Center of Health Statistics at the Centers for Disease Control (CDC) and jointly approved by the CDC and the Centers for Medicare and Medicaid Services (CMS).⁶

Both pure and menstrual-related migraines without aura have been assigned new ICD-9-CM codes, effective October 2008 and are as follows^6,7:

Table 1. ICD-9-CM and ICHD-II Codes, effective as of October 2008

The table reflects changes in headache code classification entitled: Other Headache Syndromes, with six subcategories and 23 new codes.⁷ Practitioners need to become familiar with the new classification system and resultant coding structure to ensure accurate diagnosis and billing. ^5-7

Resource Links

International Headache Society Classification of ICHD-II:
http://ihs-classification.org/en/

American Headache Society ICD-9-CM and ICHD-II Codes Table
www.americanheadachesociety.org/uploads/FTP_documents/D2492322B6194060AB8597839F79508F.xls

References

1. Martin VT, Lipton RB. Epidemiology and biology of menstrual migraine. Headache. 2008;48 Suppl 3:S124-130. Review.
2. Scharfman HE, MacLusky NJ.Estrogen-growth factor interactions and their contributions to neurological disorders. Headache. 2008;48 Suppl 2:S77-89. Review.
3. Mickey BJ, Ducci F, Hodgkinson CA, et al. Monoamine oxidase A genotype predicts human serotonin 1A receptor availability in vivo. J Neurosci. 2008;28(44):11354-11359.
4. Lothe A, Merlet I, Demarquay G, et al. Interictal brain 5-HT1A receptors binding in migraine without aura: A 18F-MPPF-PET study. Cephalalgia. 2008;28(12):1282-1291.
5. International Headache Society Classification of ICHD-II. Accessed March 30, 2009 at: http://ihs-classification.org/en/ and http://ihs-classification.org/en/02_klassifikation/05_anhang/01.01.02_anhang.html
6. The American Headache Society. Accessed March 30, 2009 at: www.americanheadachesociety.org/professionalresources/news/article.asp?article_id=49
7. The American Headache Society. ICD-9-CM and ICHD-II Codes Table. Accessed March 30, 2009 at: www.americanheadachesociety.org/uploads/FTP_documents/D2492322B6194060AB8597839F79508F.xls