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					Migraine and headache in older people
A recent report by the World Health Organisation ranks migraine as one of
the most disabling chronic conditions and equates a day of severe migraine
to the disability associated with a day of quadriplegia, psychosis, or
dementia. Migraine is particularly challenging in older people. In part two of
this two part article, Dr Nabil Aly discusses diagnosis and management of
headaches and migraine in the elderly.

Migraine is a common, chronic, incapacitating neurovascular disorder. It is
characterised by attacks of severe headache and autonomic nervous system
dysfunction. And there can, in some patients, be an aura involving
neurological symptoms in addition to gastrointestinal symptoms and/or visual
disturbances occurring during the attack.

A recent report by the World Health Organisation ranks migraine as one of
the most disabling chronic conditions and equates a day of severe migraine
to the disability associated with a day of quadriplegia, psychosis, or
dementia1. In contrast, headache (or cephalgia) is simply a ‘pain in the head’
of various characters.

Pathophysiology

The mechanisms of migraine are not completely understood. However, new
technologies have allowed the development of current concepts that may
explain parts of the migraine syndrome. For many years, headache pain
during a migraine attack was thought to be a reactive hyperaemia in
response to vasoconstriction-induced ischaemia during aura (vascular
theory). This explained the throbbing quality of the headache, its varied
localisation, and the relief obtained from ergots; however, it did not explain
the prodrome and associated features, the efficacy of some drugs used to
treat migraines that have no effect on blood vessels, and the fact that most
patients do not have an aura.

Diagnosis

Although headache is a very common reason for physician visits and clinic
appointments, the majority of headache complaints are benign in origin.
However, migraine with its protean manifestation may simulate or be
simulated by primary and secondary headache disorders. Also, it can co-
exist with a secondary headache disorder. When headache is episodic,
recurrent, and with a well-established pattern, a primary headache disorder
is likely.
Differentiating between migraine, tension-type, and cluster headaches is
important, as optimal treatment may differ. Headaches indicating a serious
underlying problem, such as tumour, stroke or malignant hypertension, are
uncommon and it should be emphasised that a headache is not a common
symptom of a brain tumour. People with existing chronic headaches,
however, might miss a more serious condition believing it to be one of their
usual headaches. Such patients should contact their general practitioner
promptly if the quality of a headache or accompanying symptoms has
changed.

Any of the following features suggest a secondary headache disorder and
warrant further investigation:
      Atypical history or unusual character that does not fulfil the criteria
         for migraine
      Occurrence of a new, different, or truly ‘worst’ headache
      Change in frequency of episodes or major characteristics of the
         headache
      Abnormal neurological examination
      Inadequate response to optimal therapy.

Severe headache of sudden onset is a concern despite its occurrence in
primary headache disorders. Migraine, cluster headache, exertional headache
or coital headache should be considered as a possible cause. However, it is
important to exclude ruptured intracranial aneurysm, aneurysmal
subarachnoid haemorrhage or arterial dissection as a cause of acute severe
headache. Rarely, it may be caused by a brain space-occupying lesion
mimicking migraine.

Investigations

Migraine beginning after age 65 years is extremely uncommon (occurring in
up to two per cent of persons) and warrants thorough investigation 2,3. Since
up to one third of headaches in the elderly are attributable to a secondary
cause, physicians should maintain a high index of suspicion for secondary
headaches2,4. A thorough history, medication history (including herbal and
other supplements), physical examination, laboratory studies and, often,
neuroimaging are therefore warranted to investigate new-onset headaches
in this population5,6.

Imaging studies
Neuroimaging studies that may be appropriate include Computed
Tomography (CT) scan and Magnetic Resonance Imaging (MRI). Other
studies such as angiography, magnetic resonance angiography, and
magnetic resonance venography also may be indicated. Neuroimaging is
indicated for any of the following:
       First or worst headache of the patient’s life
       Change in frequency, severity, or clinical features of the headache
       Abnormal neurological examination
       Progressive or new daily, persistent headache
       Neurological symptoms that do not meet the criteria for migraine
         with typical aura or that themselves warrant investigation
       Persistent neurological deficit
       Hemicrania that is always on the same side and associated with
         contralateral neurological symptoms
       Inadequate response to routine therapy
       Atypical clinical presentation.


Cerebrospinal fluid study
Neuroimaging (CT scan or MRI) should precede Lumbar Puncture (LP) test
to rule out a mass lesion and/or increased Intracranial pressure. Indications
for LP include the following:
        First or worst headache of a patient’s life
        Severe, rapid-onset, recurrent headache
        Progressive headache
        Atypical chronic intractable headache.


Management

Because of coexisting medical conditions and polypharmacy, abortive and
prophylactic treatment strategies are challenging in the elderly 7. Altered drug
distribution, metabolism, and elimination predispose geriatric patients to
medication toxicity5. Hence, migraine treatment in these patients requires
both non-pharmacological and pharmacological treatment methods.
Regulating daily activities (such as maintaining regular mealtimes and sleep
schedules) and avoiding identifiable triggers (such as limiting caffeine
intake) may assist those with frequent migraines. Training in relaxation,
biofeedback, stress management, and cognitive-behaviour therapy may be
beneficial in some elderly migraineurs. If the episodes of migraine are
frequent, preventative treatment can be considered with medications such as
verapamil, topiramate, divalproex sodium, aspirin, and clopidogrel. Beta-
blockers should be avoided because of the potential for worsening of
vasospasm. For acute treatment, ergotamine, dihydroergotamine, and triptans
should be avoided because of the risk of increasing cerebral vasospasm.
Abortive-therapy
A useful approach is to maximise drug efficacy by treating early in an acute
attack and as aggressively as warranted to avoid the risks of repeated
dosing. Close follow-up is crucial, and direct questioning should address use
of over-the-counter medication to avoid rebound headache and to minimise
the risks of adverse effects. First-line therapy with paracetamol
(acetaminophen), acetylsalicylic acid, and non-steroidal anti-inflammatory
drugs, while efficacious, should be used cautiously owing to the risks of
gastrointestinal bleeding and renal and hepatic insufficiency. Adjunctive
therapy with anti-emetics can be particularly helpful. However, the elderly
are vulnerable to the sedative and extra-pyramidal side effects of anti-
emetics. Clinical studies evaluating dihydroergotamine and the triptans have
excluded patients older than 65 years. Furthermore, triptans are
contraindicated in patients with a history of, or significant risk factors for,
cardiovascular, cerebrovascular, or peripheral vascular disease.

Patients who have tolerated triptans well over the years may continue taking
triptans past age 65 years only in the absence of new contraindications and
in conjunction with periodic screening (including electrocardiogram, cardiac
stress test) for silent cardiac disease. There is no evidence from clinical
experience that triptans are less safe after age 65 years when prescribed
appropriately. Therefore, in the absence of contraindications or significant
risk factors for vascular disease, triptans are used in practice in the elderly
with considerable efficacy. This is especially true for patients with severe
migraine attacks that result in functional impairment and have not responded
adequately to over-the-counter or prescription analgesics. In addition,
opioids should be used judiciously because of sedation and cognitive side
effects but may be necessary for severe or disabling attacks.

Prophylactic-therapy
Prophylactic options are limited in the older population because of
contraindications and side effects. In this population, the adage ‘start low and
go slow’ is particularly appropriate. Beta-blockers (such as propranolol or
nadolol) may be helpful but are contraindicated with concomitant asthma,
chronic obstructive pulmonary disease, congestive heart failure, and
hypotension. It can also lead to unacceptable lethargy or confusion. Tricyclic
antidepressants are contraindicated with concomitant cardiac dysrhythmia,
urinary retention, closed-angle glaucoma, and prostatic enlargement and can
result in intolerable sedation, confusion, urinary retention, conduction block, or
orthostatic hypotension. The anticonvulsants valproate, topiramate, and
gabapentin may be useful but can have significant cognitive and other central
nervous system side effects, including sedation.
Conclusion

Treating migraine in the elderly can be both extremely challenging and
immensely rewarding. Failure to adequately treat migraine in these patients
can lead to excessive disability and significant burden for both the patient
and his or her family. An organised approach to migraine in these
populations can lead to safe and effective therapy.

For part one of this article, click here

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References

    1. Goadsby PJ, Lipton RB, Ferrari MD. Migraine-current understanding and treatment. N
       Engl J Med 2002; 346(4): 257-70

    2. Edmeads J. Headaches in older people: How are they different in this age-group?
       Postgrad Med 1997; 101(5): 91-100

    3. Selby GW, Lance JW. Observation of 500 cases of migraine and allied vascular
       headache. J Neurol Neurosurg Psychiatry 1960; 23: 23-32

    4. Pascual J, Berciano J. Experience in the diagnosis of headaches that start in elderly
       people. J Neurol Neurosurg Psychiatry 1994; 57(10): 1255–7

    5. Biondi DM, Saper JR. Geriatric headache: how to make the diagnosis and manage
       the pain. Geriatrics 2000; 55(12): 40–50

    6. Capobianco D. Headache in the elderly. Adv Stud Med 2003; 3(6c): S556–61

    7. Ward TN. Headache disorders in the elderly. Curr Treat Options Neurol 2002; 4(5):
       403-8

				
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