Nancy A. Melville

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. – Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol.

“I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added. “Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

Short-term prophylaxis approaches recommended range from NSAIDS to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressants, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. – Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol.

“I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added. “Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

Short-term prophylaxis approaches recommended range from NSAIDS to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressants, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. – Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol.

“I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added. “Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

Short-term prophylaxis approaches recommended range from NSAIDS to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressants, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. — Because fluctuating hormones are believed to be the key culprit behind menstrual migraines, low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Ob.gyns. often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. “I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, said Dr. Lay.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said, adding that the estrogen patch is another effective way of providing a more steady level of estrogen. Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said in an interview

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally. “We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes.”

Short-term prophylaxis approaches recommended to prevent the onset of menstrual migraines range from NSAIDs to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressant, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. — Because fluctuating hormones are believed to be the key culprit behind menstrual migraines, low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Ob.gyns. often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. “I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, said Dr. Lay.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said, adding that the estrogen patch is another effective way of providing a more steady level of estrogen. Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said in an interview

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally. “We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes.”

Short-term prophylaxis approaches recommended to prevent the onset of menstrual migraines range from NSAIDs to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressant, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. — Because fluctuating hormones are believed to be the key culprit behind menstrual migraines, low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Ob.gyns. often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. “I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, said Dr. Lay.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said, adding that the estrogen patch is another effective way of providing a more steady level of estrogen. Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said in an interview

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally. “We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes.”

Short-term prophylaxis approaches recommended to prevent the onset of menstrual migraines range from NSAIDs to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressant, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

PHOENIX, ARIZ. — The presence of an isolated intracardiac echogenic focus on fetal ultrasound does not increase the risk for aneuploidy in the absence of other risk factors in women younger than 35 years of age, Kathleen Bradley, M.D., reported at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Consequently, amniocentesis may not be indicated in these patients, she said.

Dr. Bradley and her associates conducted a study that involved 10,875 patients who had an ultrasound evaluation in the second trimester at Cedars-Sinai Medical Center, Los Angeles, from 1997 to 1999.

A total of 176 cases, or 1.6%, of fetal intracardiac echogenic foci (IEF) were identified. Among them, 80% had an isolated IEF finding, and 20% had other ultrasound findings.

Abnormal karyotypes were identified in the fetuses of three IEF patients. Each of the three patients was at least 35 years old. The three fetuses all had trisomy 21, according to Dr. Bradley, a perinatologist in Tarzana, Calif.

“Our findings suggest that there is not an increased risk of aneuploidy with isolated IEF where there are no other risk factors in women” aged 35 or younger, Dr. Bradley said at the meeting, which was cosponsored by the American College of Obstetricians and Gynecologists.

Dr. Bradley noted a larger study of 12,672 patients evaluated in the second trimester. There were 479 cases of IEF and 11 cases of trisomy 21. Only one fetus with trisomy 21 had an isolated echogenic focus (J. Ultrasound Med. 2004;23:489–96).

“These trends may be helpful for current clinical management,” Dr. Bradley said. She urged a move toward individualized risk assessment to include factors such as advanced maternal age, biochemical screening, and all ultrasound markers, given a relative risk for each soft marker.

“It is important to determine a critical cutoff level to offer invasive clinical diagnosis. Should we use the current age-based risk or the procedure-related risk?” she asked. In addition, Dr. Bradley noted that of the 97 patients involved in the study and who underwent amniocentesis, there were no procedure-related losses.

In a comment on the study, Roger Rowles, M.D., a Yakima, Wash., ob.gyn., emphasized that the findings, along with the larger study, offer important insights into the use of amniocentesis for isolated intracardiac echogenic foci.

“The reasonable conclusion is that finding an IEF should prompt a detailed anatomic survey and, in the absence of other ultrasound markers and risk factors, patients should not be offered amniocentesis,” he said.

PHOENIX, ARIZ. — The presence of an isolated intracardiac echogenic focus on fetal ultrasound does not increase the risk for aneuploidy in the absence of other risk factors in women younger than 35 years of age, Kathleen Bradley, M.D., reported at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Consequently, amniocentesis may not be indicated in these patients, she said.

Dr. Bradley and her associates conducted a study that involved 10,875 patients who had an ultrasound evaluation in the second trimester at Cedars-Sinai Medical Center, Los Angeles, from 1997 to 1999.

A total of 176 cases, or 1.6%, of fetal intracardiac echogenic foci (IEF) were identified. Among them, 80% had an isolated IEF finding, and 20% had other ultrasound findings.

Abnormal karyotypes were identified in the fetuses of three IEF patients. Each of the three patients was at least 35 years old. The three fetuses all had trisomy 21, according to Dr. Bradley, a perinatologist in Tarzana, Calif.

“Our findings suggest that there is not an increased risk of aneuploidy with isolated IEF where there are no other risk factors in women” aged 35 or younger, Dr. Bradley said at the meeting, which was cosponsored by the American College of Obstetricians and Gynecologists.

Dr. Bradley noted a larger study of 12,672 patients evaluated in the second trimester. There were 479 cases of IEF and 11 cases of trisomy 21. Only one fetus with trisomy 21 had an isolated echogenic focus (J. Ultrasound Med. 2004;23:489–96).

“These trends may be helpful for current clinical management,” Dr. Bradley said. She urged a move toward individualized risk assessment to include factors such as advanced maternal age, biochemical screening, and all ultrasound markers, given a relative risk for each soft marker.

“It is important to determine a critical cutoff level to offer invasive clinical diagnosis. Should we use the current age-based risk or the procedure-related risk?” she asked. In addition, Dr. Bradley noted that of the 97 patients involved in the study and who underwent amniocentesis, there were no procedure-related losses.

In a comment on the study, Roger Rowles, M.D., a Yakima, Wash., ob.gyn., emphasized that the findings, along with the larger study, offer important insights into the use of amniocentesis for isolated intracardiac echogenic foci.

“The reasonable conclusion is that finding an IEF should prompt a detailed anatomic survey and, in the absence of other ultrasound markers and risk factors, patients should not be offered amniocentesis,” he said.

PHOENIX, ARIZ. — The presence of an isolated intracardiac echogenic focus on fetal ultrasound does not increase the risk for aneuploidy in the absence of other risk factors in women younger than 35 years of age, Kathleen Bradley, M.D., reported at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Consequently, amniocentesis may not be indicated in these patients, she said.

Dr. Bradley and her associates conducted a study that involved 10,875 patients who had an ultrasound evaluation in the second trimester at Cedars-Sinai Medical Center, Los Angeles, from 1997 to 1999.

A total of 176 cases, or 1.6%, of fetal intracardiac echogenic foci (IEF) were identified. Among them, 80% had an isolated IEF finding, and 20% had other ultrasound findings.

Abnormal karyotypes were identified in the fetuses of three IEF patients. Each of the three patients was at least 35 years old. The three fetuses all had trisomy 21, according to Dr. Bradley, a perinatologist in Tarzana, Calif.

“Our findings suggest that there is not an increased risk of aneuploidy with isolated IEF where there are no other risk factors in women” aged 35 or younger, Dr. Bradley said at the meeting, which was cosponsored by the American College of Obstetricians and Gynecologists.

Dr. Bradley noted a larger study of 12,672 patients evaluated in the second trimester. There were 479 cases of IEF and 11 cases of trisomy 21. Only one fetus with trisomy 21 had an isolated echogenic focus (J. Ultrasound Med. 2004;23:489–96).

“These trends may be helpful for current clinical management,” Dr. Bradley said. She urged a move toward individualized risk assessment to include factors such as advanced maternal age, biochemical screening, and all ultrasound markers, given a relative risk for each soft marker.

“It is important to determine a critical cutoff level to offer invasive clinical diagnosis. Should we use the current age-based risk or the procedure-related risk?” she asked. In addition, Dr. Bradley noted that of the 97 patients involved in the study and who underwent amniocentesis, there were no procedure-related losses.

In a comment on the study, Roger Rowles, M.D., a Yakima, Wash., ob.gyn., emphasized that the findings, along with the larger study, offer important insights into the use of amniocentesis for isolated intracardiac echogenic foci.

“The reasonable conclusion is that finding an IEF should prompt a detailed anatomic survey and, in the absence of other ultrasound markers and risk factors, patients should not be offered amniocentesis,” he said.

LAS VEGAS — Behavioral therapies can break the habits and misconceptions that cause chronic insomnia, provided that psychiatric or medical problems are not at play, Dr. Bashir Chaudhary said at a meeting on primary care sponsored by the Southern Medical Association.

Among patients with chronic insomnia (lasting longer than 6 months), the cause is psychiatric in about 35% of cases, psychophysiologic in 15%, related to use of drugs or alcohol in 12%, restless legs syndrome in 12%, and sleep apnea in 6%, said Dr. Chaudhary, emeritus professor of medicine at the Medical College of Georgia, Augusta, and director of the Georgia Sleep Center at the college.

In the absence of medical and psychiatric problems, chronic insomnia may be caused by psychophysiologic factors, in which the patients' anxiety about lack of sleep becomes a big part of the problem.

“These are people who are stressed about sleep all day long,” Dr. Chaudhary said. “They become obsessively worried about it.” Such patients often have conditioned themselves to experience insomnia in their own sleeping environment; if they sleep elsewhere—in another room or at another place—they often have no problem falling or staying asleep.

Other forms of insomnia can typically be swiftly corrected by addressing direct causes, but psychophysiologic cases can often take more effort on the part of the patient and the physician. “Most of the time I spend in cognitive therapy is with these patients,” he said, adding that behavioral techniques and lifestyle guidelines can be effective.

One behavioral therapy approach is stimulus control, which aims to decrease cues for nighttime arousals and focus on cues that help induce sleep. Some key recommendations include:

▸ Go to bed only when sleepy.

▸ Get out of bed if not asleep within 20 minutes.

▸ Wake up at the same time every day. “This is the most important,” he said.

▸ Do not take naps.

Sleep restriction therapy is another effective technique. Dr. Chaudhary advised asking patients how much sleep they get during a typical night, adding about 2 hours to that, and having them restrict themselves to that length of time in bed. Patients should be instructed to wake up at their regular time, but to go to bed at the time that would provide the allocated amount of sleep. If, after several weeks, patients report getting good quality sleep at least 85% of the night, then add increments of about 15 minutes. But if they are not getting the 85%, then further restrict the sleep time.

A metaanalysis of studies shows that nonpharmacologic therapies are highly successful in insomnia, with techniques improving sleep onset in 81% of cases, reducing sleep latency by 35 minutes, and resulting in 74% extension of sleep maintenance (Am. J. Psychiatry 1994;151:1172-80).

Ten Commandments of Good Sleep

As part of his cognitive therapy, Dr. Chaudhary offers patients his “Ten Commandments of Good Sleep”:

1. Thou shalt not stay in bed too long.

2. Thou shalt avoid daytime naps.

3. Thou shalt maintain the circadian cycle.

4. Thou shalt avoid stimulants after lunch.

5. Thou shalt not take a “toddy” before bedtime.

6. Thou shalt not go to bedhungry.

7. Thou shalt not smoke.

8. Thou shalt exercise regularly.

9. Thou shalt keep the bedroom at a comfortable temperature.

10. Thou shalt keep the noise down.

LAS VEGAS — Behavioral therapies can break the habits and misconceptions that cause chronic insomnia, provided that psychiatric or medical problems are not at play, Dr. Bashir Chaudhary said at a meeting on primary care sponsored by the Southern Medical Association.

Among patients with chronic insomnia (lasting longer than 6 months), the cause is psychiatric in about 35% of cases, psychophysiologic in 15%, related to use of drugs or alcohol in 12%, restless legs syndrome in 12%, and sleep apnea in 6%, said Dr. Chaudhary, emeritus professor of medicine at the Medical College of Georgia, Augusta, and director of the Georgia Sleep Center at the college.

In the absence of medical and psychiatric problems, chronic insomnia may be caused by psychophysiologic factors, in which the patients' anxiety about lack of sleep becomes a big part of the problem.

“These are people who are stressed about sleep all day long,” Dr. Chaudhary said. “They become obsessively worried about it.” Such patients often have conditioned themselves to experience insomnia in their own sleeping environment; if they sleep elsewhere—in another room or at another place—they often have no problem falling or staying asleep.

Other forms of insomnia can typically be swiftly corrected by addressing direct causes, but psychophysiologic cases can often take more effort on the part of the patient and the physician. “Most of the time I spend in cognitive therapy is with these patients,” he said, adding that behavioral techniques and lifestyle guidelines can be effective.

One behavioral therapy approach is stimulus control, which aims to decrease cues for nighttime arousals and focus on cues that help induce sleep. Some key recommendations include:

▸ Go to bed only when sleepy.

▸ Get out of bed if not asleep within 20 minutes.

▸ Wake up at the same time every day. “This is the most important,” he said.

▸ Do not take naps.

Sleep restriction therapy is another effective technique. Dr. Chaudhary advised asking patients how much sleep they get during a typical night, adding about 2 hours to that, and having them restrict themselves to that length of time in bed. Patients should be instructed to wake up at their regular time, but to go to bed at the time that would provide the allocated amount of sleep. If, after several weeks, patients report getting good quality sleep at least 85% of the night, then add increments of about 15 minutes. But if they are not getting the 85%, then further restrict the sleep time.

A metaanalysis of studies shows that nonpharmacologic therapies are highly successful in insomnia, with techniques improving sleep onset in 81% of cases, reducing sleep latency by 35 minutes, and resulting in 74% extension of sleep maintenance (Am. J. Psychiatry 1994;151:1172-80).

Ten Commandments of Good Sleep

As part of his cognitive therapy, Dr. Chaudhary offers patients his “Ten Commandments of Good Sleep”:

1. Thou shalt not stay in bed too long.

2. Thou shalt avoid daytime naps.

3. Thou shalt maintain the circadian cycle.

4. Thou shalt avoid stimulants after lunch.

5. Thou shalt not take a “toddy” before bedtime.

6. Thou shalt not go to bedhungry.

7. Thou shalt not smoke.

8. Thou shalt exercise regularly.

9. Thou shalt keep the bedroom at a comfortable temperature.

10. Thou shalt keep the noise down.

LAS VEGAS — Behavioral therapies can break the habits and misconceptions that cause chronic insomnia, provided that psychiatric or medical problems are not at play, Dr. Bashir Chaudhary said at a meeting on primary care sponsored by the Southern Medical Association.

Among patients with chronic insomnia (lasting longer than 6 months), the cause is psychiatric in about 35% of cases, psychophysiologic in 15%, related to use of drugs or alcohol in 12%, restless legs syndrome in 12%, and sleep apnea in 6%, said Dr. Chaudhary, emeritus professor of medicine at the Medical College of Georgia, Augusta, and director of the Georgia Sleep Center at the college.

In the absence of medical and psychiatric problems, chronic insomnia may be caused by psychophysiologic factors, in which the patients' anxiety about lack of sleep becomes a big part of the problem.

“These are people who are stressed about sleep all day long,” Dr. Chaudhary said. “They become obsessively worried about it.” Such patients often have conditioned themselves to experience insomnia in their own sleeping environment; if they sleep elsewhere—in another room or at another place—they often have no problem falling or staying asleep.

Other forms of insomnia can typically be swiftly corrected by addressing direct causes, but psychophysiologic cases can often take more effort on the part of the patient and the physician. “Most of the time I spend in cognitive therapy is with these patients,” he said, adding that behavioral techniques and lifestyle guidelines can be effective.

One behavioral therapy approach is stimulus control, which aims to decrease cues for nighttime arousals and focus on cues that help induce sleep. Some key recommendations include:

▸ Go to bed only when sleepy.

▸ Get out of bed if not asleep within 20 minutes.

▸ Wake up at the same time every day. “This is the most important,” he said.

▸ Do not take naps.

Sleep restriction therapy is another effective technique. Dr. Chaudhary advised asking patients how much sleep they get during a typical night, adding about 2 hours to that, and having them restrict themselves to that length of time in bed. Patients should be instructed to wake up at their regular time, but to go to bed at the time that would provide the allocated amount of sleep. If, after several weeks, patients report getting good quality sleep at least 85% of the night, then add increments of about 15 minutes. But if they are not getting the 85%, then further restrict the sleep time.

A metaanalysis of studies shows that nonpharmacologic therapies are highly successful in insomnia, with techniques improving sleep onset in 81% of cases, reducing sleep latency by 35 minutes, and resulting in 74% extension of sleep maintenance (Am. J. Psychiatry 1994;151:1172-80).

Ten Commandments of Good Sleep

As part of his cognitive therapy, Dr. Chaudhary offers patients his “Ten Commandments of Good Sleep”:

1. Thou shalt not stay in bed too long.

2. Thou shalt avoid daytime naps.

3. Thou shalt maintain the circadian cycle.

4. Thou shalt avoid stimulants after lunch.

5. Thou shalt not take a “toddy” before bedtime.

6. Thou shalt not go to bedhungry.

7. Thou shalt not smoke.

8. Thou shalt exercise regularly.

9. Thou shalt keep the bedroom at a comfortable temperature.

10. Thou shalt keep the noise down.