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  1. 1. 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.
  2. 2. 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 investigation2,3. 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
  3. 3. 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 elderly7. 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.
  4. 4. 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
  5. 5. 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 Links Return to Archive Main Page 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