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Women With Migraine: Effective Strategies for Positive Outcomes

  • Authors: Lawrence C. Newman, MD
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Target Audience and Goal Statement

Neurologists, family physicians, general practice physicians, internal medicine specialists, gynecologists, and other healthcare professionals who treat female patients with migraine.

Upon completion of this activity, participants should be able to:

  1. Conduct patient assessment of headache to ensure appropriate diagnosis and targeted treatment.
  2. Recognize the direct and indirect impact of migraine on women.
  3. Select treatment approaches that improve migraine relief and reduce recurrence in women, resulting in patient satisfaction and compliance.
  4. Utilize the most effective strategies to prevent migraine attacks and improve patient quality of life.


  • Lawrence C Newman, MD

    Associate Clinical Professor of Neurology, Albert Einstein College of Medicine, Bronx, New York; Director, The Headache Institute, New York; Associate Professor of Neurology, Albert Einstein College of Medicine, Bronx, New York.


    Disclosure: Clinical Investigator: Allergan, AstraZeneca, Abbott, Elan, Endo, GlaxoSmithKline, Pfizer, Merck, Ortho-McNeil; Research Consultant: Allergan, AstraZeneca, Abbott, Elan, Endo, GlaxoSmithKline, Pfizer, Merck, Ortho-McNeil.

Accreditation Statements

    For Physicians

  • Professional Postgraduate Services® is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

    Thomson Professional Postgraduate Services designates this educational activity for a maximum of 1.5 Category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

    This activity has been reviewed and is acceptable for up to 1.5 Prescribed credit(s) by the American Academy of Family Physicians. AAFP accreditation begins 12/01/05. Term of approval is for one-year(s) from this date with option for yearly renewal.

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For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

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There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

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  1. Read the target audience, learning objectives, and author disclosures.
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Women With Migraine: Effective Strategies for Positive Outcomes: Primary and Secondary Headache Classifications


Primary and Secondary Headache Classifications

  • Now how do we diagnose primary or secondary headaches? Well, the basis of the diagnosis of a primary headache really rests upon the symptoms themselves. Recently the International Headache Society (IHS) Classification, second edition (ICHD-2), was released to distinguish various types of headaches, the clinical features of various types of headaches. And as you can see from this slide, primary headache is based on symptoms. It's a tool that now is available to measure and monitor patient disability, whereas secondary headache disorders are based on etiology, whether it's due to stroke, subarachnoid hemorrhage, infection, sinusitis, or one of the many different causes of headache. How we distinguish between the 2 can be difficult, but in general there are red flags in both the history and on the physical exam that can separate between a primary and a secondary headache disorder.

  • Slide

    Slide 8.

    IHS Classification: ICHD-2

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  • As you see here, the red flags for secondary headaches are listed, and we use the mnemonic SSNOOP, which refers to a number of different characteristics in the headache history, clinical features, and examinations that can tip you off as to whether you're dealing with an ominous cause of headache. So the first S, systemic symptoms, is referring to weight loss or fever or joint pains or body aches, which should suggest an underlying infectious or systemic inflammatory disorder. Newly acquired neurologic signs or symptoms should always raise concern for an underlying disorder. The second S, secondary risk factors, such as an underlying disease, whether HIV or systemic cancer, should raise the specter of a more serious disorder in an immunocompromised host. Neurologic symptoms or abnormal signs on the neurologic examination, such as a change in the mental status, a waxing and waning mental status or impairment in alertness, should clue the physician that an ominous cause is probablyat play.

    How does the headache begin? The onset, such as a sudden onset or the worst headache of their life or headache that crescendos rapidly, also should clue the physician that he or she is dealing with a subarachnoid hemorrhage or other form of intracerebral bleed. Headaches that begin in an older population, either a new onset of headache after age 50 or a change in an established pattern of headache after age 50, are an organic cause of headache until proven otherwise. In this subpopulation, the idea of mass lesions or systemic illness such as giant-cell arteritis always needs to be entertained. And finally, a previous headache history or a progression of a known headache -- whether the pattern has changed or that this is the first headache or a change in an established pattern of headache or whether other clinical features are at play -- need to come into the history to rule out secondary vs. primary causes of headache. When Jessie discussed her headache, none of these factorslisted under SSNOOP were evident.

  • Slide

    Slide 9.

    Secondary Headache Red Flags: "SSNOOP"

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