Pain at Midlife

Mary Ellen Rousseau, CNM, MS; Sarabeth F. Gottlieb, CNM, MSN

J Midwifery Womens Health. 2004;49(6)

Abstract and Introduction

Although menopause is a normal developmental milestone through which all women pass, the transition has been long associated with chronic pain conditions that may be more accurately viewed as secondary to aging. Clinicians need to understand management of pain problems women may experience. This article examines pain syndromes including headache, back pain, osteoarthritis, pelvic pain, vulvo-vaginal pain, and burning mouth syndrome.

Women often present for gynecologic care during the perimenopausal transition with questions and concerns about pain. Women may report a variety of pain-related symptoms that are not readily explained by specific disease conditions. Some of these symptoms appear directly linked to the changes of menopause, and others do not. Some pain-related symptoms improve over time, whereas others worsen as aging proceeds. Clinicians need to understand management of the pain problems women may experience, whether or not they are related to the changing hormonal milieu. By recognizing the critical issue of distinguishing the differences between aging and menopause, this article examines an aspect of midlife aging that is frequently overlooked or misunderstood by researchers and clinicians (i.e., pain). Five common pain problems experienced by women in the menopausal age range are reviewed.

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Cite this: Pain at Midlife - Medscape - Nov 01, 2004.

Table 1. Medications for Prophylaxis Against Migraines
Category	Drug	Brand Name	Dose/Day
Beta blockers*	Atenolol	Tenormin	50-150 mg
	Metoprolol	Lopressor	50-300 mg
	Nadolol	Corzide, Corgard	20-160 mg
	Propranolol	Inderal, Inderide	40-240 mg
	Timolol	Blocadren	10-60 mg
Calcium channel blockers	Verapamil	Calan	120-480 mg
		Calan SR
		Covera-HS
		Isoptin SR
		Tarka
		Verelan PM
	Diltiazem	Cardizem	90-180 mg
	Nifedipine	Procardia	30-120 mg
Serotonin antagonists/agonists antidepressants (tricyclics)	Cyproheptadine	Periactin	4-12 mg
	Amitriptyline	Elavil	10-150 mg
	Nortriptyline	Pamelor	10-150 mg
	Doxepin	Sinequan	10-150 mg
	Imipramine	Tofranil	10-150 mg
Antidepressants (selective serotonin-reuptake inhibitors)	Fluoxetine	Prozac	10-80 mg
Antidepressants (selective serotonin-reuptake inhibitors)	Trazodone	Desyrel	50-300 mg
Anticonvulsants	Divalproex sodium	Depakote	250-1500 mg
Anticonvulsants	Gabapentin	Neurontin	300-2700 mg

* Noncardioselective beta blockers may take up to 3 months for effectiveness; always taper the dose when discontinuing.

Table 2. Medications Prescribed for Abortive Treatment of Migraine Headaches
Category	Drug	Brand Name	Dose/Day
"Triptans" 5HT₁ serotonin receptor agonists*	Sumatriptan	Imitrex	SQ: 6 mg SQ, one time dose; maximum is 12 mg/day SQ PO: 25-50 mg PO; maximum 100 mg per dose or repeat q 2 h for maximum 300 mg/24 h Nasal: 5-20 mg nasal, q 2 h; maximum of 40 mg/24 h
	Rizatriptan	Maxalt	5-10 mg PO, repeat q 2 h; maximum 30 mg/24 h
	Zolmitriptan	Zomig, Zomig ZMT	2.5-5 mg PO, repeat q 2 h; maximum 10 mg/24 h Orally disintegrating tablet (ZMT) 2.5 mg q 2 h; maximum 10 mg/day
	Naratriptan	Amerge	1-2.5 mg PO, repeat after 4 h; maximum 5 mg/24 h
	Almotriptan	Axert	6.25-12.5 mg PO; repeat q 2 h maximum 12.5/24 h
	Frovatriptan	Frova	2.5 mg PO; repeat after 2 h; maximum 7.5 in 24 h
	Eletripan	Relpax	20-40 mg PO; repeat after 2 h, maximum 80 mg/24 h
"Ergot" derivatives alpha adrenergic blockers^‡	Ergot	Migranal nasal spray	1 spray q nostril repeat 15 min; maximum 6 sprays/24 h and 8 sprays/wk
	Ergot alkaloid with caffeine	Cafergot	Oral dose: 1 mg ergotamine/100 mg caffeine; 2 tabs PO at onset followed by 1 tab q 30 min up to maximum of 6 tabs/24 h; maximum dose is 6 tabs per attack and 10 tabs/wk
	Ergot alkaloid with caffeine	Cafergot suppositories	Suppositories 2 mg ergotamine/100 mg caffeine. 2 per attack or maximum of 5 supp/wk
Others	Butabarbital + acetaminophen + caffeine	Fioricet, Esgic	50 mg/325 or 500 mg/40 mg; 1-2 tab PO q 4 h; maximum 6 daily
	Acetaminophen + aspirin + caffeine	Excedrin Migraine	250 mg/250 mg/65 mg; 2 tabs PO q 6 h; maximum 8 tabs/24 h for 2 days
	Isometheptene mucate/dichloralphenazone/acetaminophen	Midrin	65 mg/100 mg/325 mg; 1-2 caps PO q 4 h max 8 caps/24 h
	Ibuprofen	Motrin, Advil	200 mg-800 mg q 6 h

* Serotonin receptor agonists are selective for a 5-hydroxtryptamine receptor subtype that mediates vasoconstriction and are present on cranial arteries, basilar artery, and the vasculature of dura mater.
Alpha adrenergic antagonists stimulate the smooth muscle of peripheral and cranial blood vessels, cause depression of central vasomotor and inflammatory centers, and antagonize serotonin.
^‡ Ergot alkaloids interact with 5HT₁ agonists and should not be given concomitantly. Ergots are contraindicated in pregnancy.

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Pain at Midlife

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