Q&A: Plenary talk highlights medical, social needs of transgender patients with migraine

One of several plenary sessions at the American Headache Society Annual Meeting, which is being held virtually, focused on sex- and gender-specific differences in headache.

The session featured talks on three topics, including sex-specific differences in pain and the question of whether sex and/or gender affect the brain’s activation patterns in pain. Healio Neurology spoke with Anna Pace, MD, assistant professor of neurology and director of the transgender headache medicine program at the Icahn School of Medicine at Mount Sinai, about her presentation, the third in the plenary session. Pace focused on the question of whether gender impacts the presentation of headache disorders, response to treatment and adherence.

Healio Neurology: Can you provide an overview of your plenary presentation?

Pace: The transgender community is largely underserved and understudied in neurology and headache medicine. Much of what is known about headache in gender-diverse individuals is extrapolated from small case series or derived from clinical experience. The presentation aimed to discuss how migraine may be affected by gender-affirming hormone therapy or gender-affirming surgical interventions and reviewed treatment options for gender-diverse patients with headache that are supportive of, and will not interact with, gender-affirming medical therapies.

Healio Neurology: What were your main take-home messages?

Pace: Based on animal and basic science models, as well as studies in cisgender individuals, it appears both estrogen and testosterone can affect the experience of pain in various ways. When treating gender-diverse patients with migraine, it is important to consider any medical or psychiatric comorbidities that may be present. Providers should be aware of any interactions that medications may have with hormones and consider neuromodulation or nonpharmacologic management as well. Understanding proper nomenclature to describe gender identity and using correct terms and pronouns when referring to patients who are transgender and gender diverse are crucial ways to help patients feel affirmed and welcomed in clinic.

Healio Neurology: How does your talk build on what we previously knew about gender’s impact in headache disorders?

Pace: Reviewing the very little literature, it appears that transgender women on estrogen may experience worsening of various pains and potentially also migraine, whereas transgender men on testosterone may experience improvement in migraine and chronic pain. Real-life experience, however, shows that each person has different responses to hormone therapy, so some may improve on estrogen once levels are stable and others on testosterone may have worsening of migraine. In general, treatment of migraine in gender-diverse patients should be individualized and all treatment should be supportive of continuation of gender-affirming hormone therapy. Patients should not have to choose between continuing hormone therapy and managing their migraines.

Healio Neurology: What are you hoping attendees take away from your talk?

Pace: I hope attendees take away the importance of creating a safe, welcoming clinical environment and the importance of providing culturally sensitive neurologic care to transgender and gender-diverse patients. We must affirm the authenticity of these individuals' identities and respect all patients. Many transgender patients are fearful of seeking care due to past experiences of discrimination and stigma. Efforts on personal, local and national levels to overcome those barriers can help gender-diverse individuals feel more comfortable pursuing medical care and returning for follow-up.

Reference:

Pace A. Does gender impact the presentation of headache disorders, response to treatment, and adherence; Learnings from clinic. Presented at: American Headache Society Annual Scientific Meeting; June 3-6, 2021 (virtual meeting).