Cluster versus migraine headache: a gender split
Cluster headache is
massively male preponderant (10:1). It is reputed to be the most painful of all
headaches. The throbbing pain is
typically unilateral and is localized behind one of the eyes. As is the case
for the vast majority of pathologies,
cluster headache has a hereditary component. Immediate family members of affected
individuals are 14 times more at risk for the condition than relatives of an
unaffected person. There seem to be many aggravating factors (alcohol,
cigarettes, allergy, orgasm, stress, brain lesions) but the most basic
mechanism seems to be neurovascular inflammation of unknown origin. Because of
the male preponderance, the effectiveness of cyproterone acetate, a synthetic
steroid with antiandrogenic action, has been tested and has been found
effective in lithium-resistant cases.
One conventional pharmacotherapy is lithium, a non-specific serotonin agonist. Curiously,
most relevant studies have shown that cluster headache male patients
have low circulating testosterone, a finding compatible with the increasing
incidence of the disease from adulthood to senescence.
Migraine is also a type of vascular headache, more prevalent in women (4:1). The throbbing pain is typically felt on one
side of the back of the head. The
syndrome is four times more frequent than cluster headache. There is a strong hereditary component. The most common treatment seems to be
GR43175, a serotonin agonist. The
unabbreviated name of this drug (3-(2-dimethylamino)
ethyl-N-methyl-1H-indole-5-methane sulphonamide), mercifully,
is not commonly used. Ergotamine, another serotonin agonist, is also
effective.
There does not seem to be any articulated model apt to
explain the sex difference in prevalence of these two pairs of very similar
disorders. Such models should be
articulated as a contribution to our global understanding of the neurobiology
of sex differences. They could be of
great help particularly in advancing our understanding of neurotransmitter
dynamics which are different in men and women.
Another female-prevalent disorder is adductor spastic
dysphonia (ASD: 1.5:1). These patients often experience a tremulous
voice associated with evidence of an essential tremor (tremor related to
action) elsewhere, including head, trunk and limbs. The mean age of onset in
patients with ASD is around 45 years. In
about half the patients the onset is gradual (suggesting a neurodegenerative
process). However, the remainder of the patients experience an
abrupt onset, related to an upper respiratory tract infection, or, more often,
to psychosocial stress. Factors which frequently result in a worsening of
speech include stress, public speaking, tiredness, strong emotions, upper
respiratory tract infections and prolonged use of the voice. A few patients with severe symptoms undergo
recurrent laryngeal nerve sectioning.
Another treatment for the most severe cases consists of local injections
of botulinum toxin (Botox) bilaterally into the vocalis muscles. My hunch as to why there is a .5% greater
incidence of this disorder in women is simply that the precipitating factor of
stress affects women more than men. We
will see in upcoming sections that women are more susceptible to developing
personality disorders that are stress-related.
A vignette on a case of hysterical aphonia
McCue and McCue reported a case of hysterical aphonia in a 1988
issue of the American Journal of Clinical
Hypnosis. The patient was a 44 year
old woman who, shortly after onset of
marital discord (loss of employment, violence, litigation, etc.), had a panic attack on a bus, lost consciousness and was hospitalized. Upon awakening she could not move or
speak. Upon examination, she was hyperventilating. She soon recovered all her movements -except
speech. She understood what was said
to her. She expressed herself by
writing, gesticulating and drawing. She was able to speak under hypnosis only. As marital reconciliation progressed, she recovered her speech, though she occasionally stuttered. She reported feeling very anxious. Two and a half years later, she had separated from her husband and was
feeling much better and had no speech problem at all.
Though each sex is at risk for its own set of
neurological problems, overall, the human male fetus seems to be at a slight
disadvantage in face of any kind of diffuse physiological stressor: such stressors include prematurity and low
birth weight, and various poisons. In a study reported by June Reinisch, sex
differences were analyzed in children whose mothers had taken barbiturates
during pregancy. Barbiturates reportedly
have been prescribed in as many as 25% of pregnancies in the US and Europe over
the last 30 years. Nevertheless, there are little if any data on long-term
consequences of prenatal exposure to barbiturates in humans. Evidence from
laboratory animals indicates that barbiturate exposure during early development
results in abnormal neural and biochemical differentiation of the CNS, deficits
in learning, retarded attainment of developmental milestones, alteration of
behavioral and physiological sex differences, increased activity, and decreased
responsiveness to aversive and appetitive stimuli. Barbiturates appear to
influence the brain via 2 routes: by direct action on neural tissue and
indirectly by altering hepatic metabolism of steroid hormones. In her study
Reinisch concluded that prenatal exposure to barbiturates in human subjects may
lead to learning disabilities, decreased IQ, performance deficits, increased
incidence of psychosocial maladjustment, and demasculinization of gender
identity and sex-role behavior in boys.
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