Managing migraine in older patients

Updated July 2021; first published Dec 2011

The International Headache Society (IHS) classifies two major subtypes of migraine. The first is migraine without aura and this is the most common, and usually more disabling, subtype. It is characterised by attacks lasting four to 72 hours that are typically of moderate to severe pain intensity, unilateral, pulsating, aggravated by normal physical activity and associated with nausea and/or photophobia and phonophobia.

Migraine with aura is characterised by reversible focal neurological symptoms that develop over a period of five to 20 minutes and last for less than 60 minutes, followed by headache with the features of migraine without aura. In some cases the headache may lack migrainous features or be absent altogether.¹

Prevalence of migraine

Whilst migraine begins to resolve in the 5th and 6th decades of life in around 40% of sufferers, it is still a common complaint in the older patient.² For example, the one year prevalence of migraine in a Dutch population-based study was 5.63% in men and 20.4% in women aged over 55 years.³

Further reading: Seven reasons acupuncture can help in the treatment of migraine

A Swedish population-based study found active migraine in 8.9% of women in the age group between 60 and 64 years, 6.8% between 65 and 69 years and 3.4% between 70 and 74 years.⁴ Comparable results have been found in Denmark,5 Canada,⁶ France,⁷ China⁸ and the USA.⁹

In a Brazilian study on headache in older patients, migraine was found to be the most frequent type of headache in general. In those whose age at onset of headache was over 60 years old, tension type headache was the most frequent diagnosis.

Cervicogenic headache was the most frequent headache diagnosed as being due to a structural cause and older age groups have a higher prevalence of headaches due to structural cause than a younger population.¹⁰

Changing symptoms with increasing age

It is common for the different migraine symptoms to change over time. Patients will describe changes in the intensity of headache, severity of nausea and vomiting, frequency and duration of attacks. During ageing, migraine with aura (MA) attacks may lose the headache element, so that only visual aura symptoms remain. This does not pose a great diagnostic problem, when the patient also suffers or has suffered from MA, but uncertainty arises when these phenomena occur for the first time in a patient without headache.

In such a case, extensive search for other (vascular) causes is needed before one can diagnose the phenomena to be migrainous. Only when an extensive work-up is unremarkable, and when the symptoms are typical of migraine aura, may they be called €œmigrainous.€ Most patients have visual symptoms alone or in combination, and a typical sign is the gradual build-up and spread over time.^11,12

New onset of migraine above the age of 50 years is not rare. A Scandinavian epidemiological study found that 19% of women with migraine without aura (MoA) had an age at onset of over 50 years.¹³

However, there are few patients who develop new-onset migraine after the age of 60 years.14 When a patient in this age group develops migraine-like headache, an underlying disease such as a mass lesion or giant cell arteritis must always be ruled out.

Diagnosis of migraine

Diagnosis of migraine is largely clinical, based on the history of a severe, disabling, intermittent headache, with well periods between attacks. There are often associated features, including nausea and vomiting, photophobia, phonophobia and osmophobia and vertigo. However, the history may be less typical in an older patient.

A lower proportion of migraines are reported as unilateral in the older population, (38% in 60€“70 year olds versus 57% in 20€“40 year olds, p<0.01) or with associated symptoms (nausea=75% versus 86%, p=0.05; vomiting=30% versus 54%, p<0.05, photophobia and phonophobia=83% versus 94%, p<0.05). Other symptoms such as paleness (p=0.0441), dry mouth (p=0.0093), and anorexia (p=0.05) were more common in the older patient.¹⁴ Diary cards are invaluable in aiding diagnosis.

Samples can be downloaded from The National Migraine Centre. A brief but full neurological examination should be carried out to help exclude secondary headache types.¹⁶ This should include assessment of the cranial nerves, and limb tone, power, reflexes and coordination.

Fundoscopy is mandatory to exclude papilloedema and prompt further investigation. In older patients with headache and cognitive impairment, be cautious of diagnosing migraine without further investigation. A 2006 study found that a long history of migraine does not compromise scores on four cognitive tests predictive of memory and executive functioning.¹⁷

Comorbidities

Comorbidities are more common in the older population, and so pose particular challenges in dealing with migraines. Firstly, the symptoms of migraine itself can cause particular problems in the elderly. Migraine is commonly associated with vertiginous symptoms, and in the older patient this can increase the risk of falls and fractures. Severe vomiting may also cause dehydration.

There are also several diseases that occur more often in association with migraine than expected by their prevalence in the general population.¹⁸ An example is ischaemic stroke, which has been associated with migraine with aura in young women in several case controlled studies.¹⁹ Extrapolating this, older patients with migraine with aura should have their vascular risk factors assessed annually.

There is an association between migraine and depression in all age groups, with a high comorbidity in older migraineurs. This can influence the patient’s perception of pain intensity and disability from migraine. It may also influence treatment choices.

Clinical management of migraine

It is always important to discuss trigger factors and explain how avoidance of these can significantly reduce the number of attacks.

These usually act in combination, building up to a threshold, and triggering the attack. By noting potential triggers every day and keeping them to a minimum, it is possible to reduce the frequency of migraine attacks. Going too long without eating or drinking are major triggers for migraine. Maintaining stable blood sugar and hydration by eating and drinking regularly throughout the day can be very effective at preventing attacks. Ideally, we recommend a snack every 3€“4 hours and at least 1 litre of fluid daily.

The early morning migraine attack is often precipitated by an early evening meal and subsequent fall in blood sugar overnight. This can be avoided in many cases, by having a simple slow release bedtime snack, such as brown toast and peanut butter, or an oatcake and cheese.

Warning features in the history¹⁵

New onset headache in a patient older than 50 years
Headache that is new or unexpected in an individual patient
Tunderclap headache (intense headache with abrupt or €œexplosive€ onset)
Headache with atypical aura (duration >1 hour or including motor weakness)
Persistent morning headache with nausea
Progressive headache, worsening over weeks or longer
Headache associated with postural change
New onset headache in a patient with a history of cancer or HIV infection

Drug management of migraine

Comorbidities and polypharmacy become more common in advancing age, making management of migraine more challenging.

According to the BASH (British Association for the Study of Headache) guidelines when prescribing acute treatments there are two broad strategies:

Stepped approach: start with simple analgesics and if ineffective step-up e.g. to a triptan
Stratified approach: target treatment based on attack severity

The stratified approach is associated with better health related outcomes and lower indirect costs (e.g. GP and hospital visits). Adding an anti-emetic to an acute treatment improves efficacy unrelated to nausea and/or vomiting and can improve gastric motility and hence drug absorption.

The end point of an effective treatment is a significant response at two hours, because the natural history for most attacks is to spontaneously improve in 4 hours. If a treatment is not effective at 2 hours, then it is unlikely to work in that attack at that dose and considering an alternative acute treatment or combination treatment would be reasonable.

Lack of response to one triptan does not predict response to other triptans. Triptans are most effective when taken early in the headache phase of the attack and are less likely to be effective at treating the headache if taken during the preceding aura.

After 2 treatment failures with a particular triptan a trial with an alternative triptan is recommended. This rationale is based on the finding that in patients who experienced treatment failure in two attacks, 70% failed to respond in the third attack. Around 30% patients do not respond to any triptan.

Opioids are not recommended for the treatment of acute headache because of the significant risk of medication overuse and the most protracted withdrawal.

The latest treatment recommendations can be found on the BASH Website.

Prophylaxis of migraine

In selecting a preventative treatment, a reasonable strategy would be to consider which options might be most suitable for the individual patient, given their previous treatment, medical and other co-morbidities, personal preferences, and side effect profiles of the various treatments.

Medication overuse headache

Medication overuse headache can occur in anyone regularly treating the symptoms of headache or migraine more often than 2€“3 days a week, and is a pattern commonly seen in patients who have self-treated for several years.

Obviously some attacks may need to be treated over four or five consecutive days, so we often review the total number of days treated per month. Migraine diaries are valuable in monitoring this. If a patient is using symptomatic treatment more than 10€“15 days a month, the treatment itself may be affecting the frequency of headache.

The only way to break this cycle is to stop the drugs, which often aggravates the symptoms for a couple of weeks before improvement is seen. Alternatively, a withdrawal programme with naproxen, with or without amitriptyline, can help. The role of other preventative drugs is limited in medication overuse as their efficacy is reduced in the presence of frequently administered acute medication.

Conclusion

Many older patients will have a long history of migraines and may consult for advice following a change in their usual pattern or severity of symptoms. Migraine is still a common condition in the elderly population, and can be managed by a combination of lifestyle changes and medication. Polypharmacy and multiple comorbidities are potential challenges when treating migraines in the elderly, and medication should be used in the lowest effective dose to minimise side effects and interactions. However, even in this population, effective treatments are available and careful management can improve the quality of life.

Dr Judith Pearson, GP & Specialist Doctor, The City of London Migraine Clinic

Conflict of interest: none declared

References

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