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Managing migraine and other headache syndromes in those over 50
Maturitas 76 (2013) 243–246
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Review
Managing migraine and other headache syndromes in those over 50夽 Brett Dees, Rhonda Coleman-Jackson, Linda A. Hershey ∗ Department of Neurology, University of Oklahoma, 825 NE 10th Street, Suite 5200, Oklahoma City, OK 73104-5021, USA
a r t i c l e
i n f o
Article history: Received 26 March 2013
Keywords: Migraine in older adults Elderly headache Cervicogenic headache Late-life migraine accompaniment Medication overuse headache Abdominal migraine
a b s t r a c t Migraine in an older person may appear with sensory or motor phenomena (“late-life migraine accompaniments”), so that it may be confused with transient ischemic attack or stroke. An older patient may have cervicogenic headache in addition to migraine. Medication overuse headache is just as much of a problem in older patients as it is in younger ones. Abdominal migraine without headache can be seen in older adults as a migraine equivalent, just as it can occur in children. The most effective drugs for migraine prophylaxis in young people (divalproex, topiramate, metoprolol and propranolol) are similarly effective for those who are over the age of 50. Oral rescue drugs, including naproxen and hydroxyzine, are also useful in older adults. We need to remind older adults about the dangers of excessive use of caffeine in coffee, tea and energy drinks, since these substances can lead to daily HA and migraine equivalents. © 2013 The Authors. Published by Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Case 1 vignette: late-life migraine accompaniment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1. Diagnosis of late-life migraine accompaniment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.2. Management of late-life migraine accompaniment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Case 2 vignette: cervicogenic headache and migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.1. Diagnosis of cervicogenic headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2. Management of cervicogenic headache and migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Case 3 vignette: medication overuse headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3.1. Diagnosis of medication overuse headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3.2. Management of medication overuse headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Case 4 vignette: abdominal migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.1. Diagnosis of abdominal migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.2. Management of abdominal migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Frequent headaches (HA) are seen in about 17% of those over the age of 65, according to one large epidemiologic study [1].
夽 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. ∗ Corresponding author. Tel.: +1 405 271 4113; fax: +1 405 271 2523. E-mail address: [email protected] (L.A. Hershey).
Others have reported the frequency of HA in the elderly to be as high as 50% [2], or as low as 12% [3]. The prevalence of migraine increases from age 12 to age 40, but in the 50–59-year cohort of the American Migraine Study, it still affected 20% of women and 7% of men [4]. Pascual and Berciano [3] found that serious conditions such as ischemic and hemorrhagic stroke, temporal arteritis, post-concussive HA, or intracranial neoplasm were more likely to be present in elderly patients who complain of HA (15%, compared to 1.6% of patients under the age of 65). Medications may be the cause of HA in as many as 8% of patients who present with HA [5]. Chronic daily HA is another group of patients that includes
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those with transformed migraine, chronic tension HA and hemicrania continua [6]. Medication overuse headache (MOH), a disorder that can result from the chronic overuse of analgesics, triptans, caffeine, or other HA remedies, has a prevalence of about 1–2% among those who are over the age of 65 [7]. Abdominal migraine, which is more common in those with a family history of migraine HA, usually emerges between the ages of 3 and 10 years, and rarely persists into adulthood [8]. We present here a case with onset over 50.
without aura. She had a past medical history of hypertension, cervical spine disease and chronic daily HA. The HAs were usually right-sided and worsened significantly with certain repositioning maneuvers of the neck. She had trigger points bilaterally in the trapezius, sternocleidomastoid, and suboccipital musculature. There was limitation of range of motion of the head and neck in all planes of movement. Otherwise, her neurologic exam was nonfocal.
2. Methods
2.1. Case 1 vignette: late-life migraine accompaniment
2.2.1. Diagnosis of cervicogenic headache Cervicogenic HA is characterized by chronic continuous unilateral HA and neck pain that is exacerbated by neck movement, or sustained awkward head position [14]. Abolition of the HA with anesthetic blocks of various cervical nerve roots provides supportive evidence that the pain is attributable to the cervical spine disorder. In one recent epidemiologic study, 42% of those with cervicogenic HA had the co-occurrence of migraine [14], similar to our patient.
This 51-year-old right-handed woman had a previous history of hypertension and migraine. She arrived in the emergency room (ER) with the chief complaints of nausea, vomiting, vertigo, weakness of the right face and traveling paresthesias up and down her left arm. She had been having HAs off and on for the last few weeks, but she did not have HA at the time of this ER visit. Her examination was remarkable for high blood pressure (177/94), right ptosis, diminished sensation over the right side of the body, an upgoing right toe, but no weakness over the right face or right body. By the second day, all her symptoms and signs had resolved, except for subjective vertigo. The diffusion weighted image sequences of the MRI scan showed no signs of a new cerebral infarction.
2.2.2. Management of cervicogenic headache and migraine We started our patient on naproxen 500 mg every 12 h as needed for abortive therapy. Topiramate 25 mg twice daily was given for migraine prophylaxis. Weekly physical therapy sessions were initiated for treatment of the patient’s neck pain. After four months, the HA completely subsided, and the neck pain and range of motion improved. A multidisciplinary team approach for HA management, including physical therapy, has been shown to be effective in reducing the occurrence of a variety of HA syndromes [15]. Another treatment for cervicogenic HA includes blockage of the greater occipital nerve with a mixture of xylocaine and marcaine [14].
2.1.1. Diagnosis of late-life migraine accompaniment In his first series of 120 late-life migraine accompaniments, Fisher [9] made the point that HA occurred in only 50% of the cases. In his second series, he reported that the patients ranged in age from 40 to 73 years (the same ages as those who commonly have cerebrovascular disease), but that the traveling paresthesias of migraine were different from the pattern of paresthesias seen in those with transient ischemic attacks and strokes [10]. The spreading depression of migraine [11] is the best explanation for the “march” of paresthesias in late-life migraine accompaniments. Forty percent of patients with migraine accompaniments in Fisher’s second series had HAs [10]. This fits with our patient, who did not have HA at the time of her admission, even though she had a history of migraine, in addition to drug-overuse HAs.
2.3. Case 3 vignette: medication overuse headache
A literature search was performed for papers published up until December, 2012, using the reference database pubMed. The key words were as follows: migraine in older adults, elderly HA, latelife migraine accompaniment, cervicogenic HA, medication overuse HA, abdominal migraine in adults.
2.1.2. Management of late-life migraine accompaniment We started our patient on topiramate for HA prophylaxis, since it is one of several drugs that are recommended by the Quality Standards Subcommittee of the American Academy of Neurology for migraine prophylaxis [12]. Other Level A drugs that prevent migraine include divalproex sodium, metoprolol, and propranolol. Level A drugs are those that have been shown to be effective in at least two Class 1 clinical trials. This patient was also counseled against daily use of over-the-counter analgesic medications, since medication overuse is a common cause of chronic daily HA in older adults [7,13]. She was also counseled against the use of caffeine, since this can lead to daily HA [7]. 2.2. Case 2 vignette: cervicogenic headache and migraine This 54-year-old right-handed woman had a strong family history of migraine HA and a personal history of migraine with and
This 67-year-old right-handed woman had a strong family history of migraine HA and a personal history of migraine HA with and without visual aura since the age of 13. She had a past medical history that was positive for diverticulitis, gastroesophageal reflux disease, gastritis, chronic diarrhea, and osteoarthritis. She came to the clinic with the complaint of chronic daily HA. An MRI had been performed a few years ago and was normal. She had been using a butalbital preparation daily since 1976. Her HAs had become steadily more severe and more frequent since that time. Now her HAs were occurring on a daily basis. She was not awakened at night with the HAs, and they were not worse when lying down. She denied jaw pain, snoring, or bruxism. Her neurologic examination was unremarkable. The ESR was normal. She denied excessive use of caffeine, tea, or energy drinks. 2.3.1. Diagnosis of medication overuse headache Migraine is a common disorder that usually begins in adolescence or young adulthood, as it did in this patient. Episodic migraine is defined as occurring fewer than 15 days a month [16]. Medication overuse HA (MOH) is defined when HA occurs on 15 or more days per month, when the therapeutic agent is used excessively, and when it is used on a regular basis for three or more months prior to the worsening of the HA frequency and severity [17]. MOH can result from the overuse of analgesics, triptans, barbiturates, caffeine, or other drugs that are used acutely to manage HA [7]. Triptan overuse can produce MOH at a faster rate and with lower doses than butalbital or narcotics [17]. The prevalence rates of MOH (1–2%) are similar across different countries, and the mean age of onset is 53 [18]. There is a higher preponderance of women with MOH (74%) than men (26%). Among those who were over the age of
B. Dees et al. / Maturitas 76 (2013) 243–246
65, the prevalence of MOH in Taiwan was 1% [19] and in Italy was 1.7% [13]. 2.3.2. Management of medication overuse headache This woman was educated about both pharmacologic and nonpharmacologic HA treatment strategies. She was given a tapering dose of phenobarbital to replace the butalbital (30 mg/day of phenobarbital for every 100 mg/day of butalbital). The phenobarbital was tapered by 15 mg every 7 days until it was discontinued. In addition, divalproex was started for HA prophylaxis at a dose of 125 mg bid. When she came for her followup visit at one month, she was HA-free. Relapse rates for MOH vary from 14% to 41% at 12 months [7]. We often give hydroxyzine 25–50 mg q6 h to MOH patients in case they have breakthrough HA while they are being tapered from the overused analgesic medication. If this patient had not benefitted from this dose of divalproex, the dose could have been increased to 250 mg bid, or even 500 mg bid. Another helpful prophylactic HA treatment for MOH patients is topiramate [20]. The benefit of topiramate for MOH has been supported by several randomized clinical trials. We encourage our MOH patients to keep a HA calendar, so that HA frequency, severity and doses of rescue therapies can be closely monitored. 2.4. Case 4 vignette: abdominal migraine This 59-year-old left-handed man with a history of hypertension, nephrolithiasis, diverticulosis and esophagitis was referred to neurology clinic because of prolonged bouts of abdominal pain of unknown etiology. His mother had had migraine HA, and he himself had 1–2 non-migrainous HAs per year. He first began having the abdominal pain at the age of 52, which was characterized by sharp, constant pain in the left lower quadrant, lasting from hours at a time to months. The pain was not associated with meals, or with the time of day. Suboxone and hydrocodone were the only medications that relieved the pain. The extensive gastroenterology workup was completely negative. His neurologic exam was negative. 2.4.1. Diagnosis of abdominal migraine In pediatric populations, the most common migraine equivalent is benign positional vertigo, followed by abdominal migraine [21]. There is usually a family history of migraine HA in those who have abdominal migraine, as there was in our patient. Abdominal migraine often occurs in close temporal proximity to migraine HA and includes a myriad of symptoms, including abdominal pain, nausea, gas, bloating, loose stools, or constipation. There was recently a young adult case of abdominal migraine described in the literature, but she differed from our patient in that she had concomitant migraine HA [21]. The prognosis of abdominal migraine of childhood is usually benign, since remission usually occurs in two years. 2.4.2. Management of abdominal migraine Our patient was started on divalproex 125 mg twice daily, and after several weeks, he experienced significant decrease in his abdominal complaints. At his last appointment, he had been asymptomatic for one month. If he had not had kidney stones in the past, we could have treated him with topiramate. Other drugs that have been shown to be helpful for treating patients with abdominal migraine include flunarizine, propranolol and cyproheptadine [8,21]. 3. Conclusions Migraine in older patients may present as migraine accompaniments, where the symptoms seem more like transient ischemic
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attacks, rather than HA. These symptoms are best treated with the usual migraine prophylactic medications. Patients with migraine who have cervicogenic HA in addition to migraine are best treated with physical therapy, or nerve blocking agents, in addition to their usual migraine prophylactic medications. MOH commonly begins over the age of 50, after many years of using analgesics or other acute migraine therapies, such as triptans or butalbital. MOH is best treated by discontinuing the offending medication and starting a migraine prophylactic agent in its place. Abdominal migraine is another form of migraine equivalent. It is best treated with the usual migraine prophylactic medications. Contributors Brett Dees, Rhonda Coleman-Jackson and Linda A. Hershey are the sole contributors. Competing interest The authors have no competing interests. Provenance and peer review Commissioned and externally peer reviewed. Funding No funding issues. References [1] Cook N, Evans DA, Funkenstein H, et al. Correlates of headache in a population-based cohort of elderly. Archives of Neurology 1989;46: 1338–44. [2] Hale WE, May FE, Marks RG, Moore MT, Steward RB. Headache in the elderly: an evaluation of risk factors. Headache 1987;27: 272–6. [3] Pasqual J, Berciano J. Experience in the diagnosis of headaches that start in elderly people. Journal of Neurology, Neurosurgery and Psychiatry 1994;57:1255–7. [4] Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001;41:646–57. [5] Lipton R, Bigal M, Steiner T, Silberstein S, Olesen J. Classification of the primary headaches. Neurology 2004;63:427–35. [6] Castillo J, Munoz P, Guitera V, Pasqual J. Epidemiology of chronic daily headache in the general population. Headache 1999;39:190–6. [7] Evers S, Marziniak M. Clinical features, pathophysiology, and treatment of medication-overuse headache. Lancet Neurology 2010;9: 391–401. [8] Carson L, Lewis D, Tsou M, et al. Abdominal migraine: an underdiagnosed cause of recurrent abdominal pain in children. Headache 2011;51: 707–12. [9] Fisher CM. Late-life migraine accompaniments as a cause of unexplained transient ischemic attacks. Canadian Journal of Neurological Sciences 1980;7: 9–17. [10] Fisher CM. Late-life migraine accompaniments—further experience. Stroke 1986;17:1033–42. [11] Lauritzen M. Pathophysiology of the migraine aura. The spreading depression theory. Brain 1994;117:199–210. [12] Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Neurology 2012;78: 1337–45. [13] Prencipe M, Casini AR, Ferretti C, et al. Prevalence of headache in an elderly population: attack frequency, disability, and use of medication. Journal of Neurology, Neurosurgery and Psychiatry 2001;70: 377–81. [14] Knackstedt H, Bansevicius D, Aaseth K, et al. Cervicogenic headache in the general population: the Akershus study of chronic headache. Cephalalgia 2010;30:1468–76. [15] Wallasch TM, Angeli A, Kropp P. Outcomes of a headache-specific cross-sectional multidisciplinary treatment program. Headache 2012;52: 1094–105.
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[16] Buse DC, Manack AN, Fanning KM, et al. Chronic migraine prevalence, disability, and sociodemographic factors: results from the American Migraine Prevalence and Prevention Study. Headache 2012;52:1456–70. [17] DeFelice M, Ossipov MH, Porreca F. Update on medication-overuse headache. Current Pain and Headache Reports 2011;15:79–83. [18] Straube A, Pfaffenrath V, Ladwig KH, et al. Prevalence of chronic migraine and medication overuse headache in Germany – the German DMKG headache study. Cephalalgia 2009;30:207–13. ISSN 0333-1024.
[19] Wang SJ, Fuh JL, Lu SR, et al. Chronic daily headache in Chinese elderly: prevalence, risk factors, and biannual follow-up. Neurology 2000;54: 314–9. [20] Russell MB, Lundqvist C. Prevention and management of medication overuse headache. Current Opinion in Neurology 2012;25:290–5. [21] d’Onofrio F, Cologno D, Buzzi MG, et al. Adult abdominal migraine: a new syndrome or sporadic feature of migraine headache? A case report. European Journal of Neurology 2006;13:85–8.
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Review
Managing migraine and other headache syndromes in those over 50夽 Brett Dees, Rhonda Coleman-Jackson, Linda A. Hershey ∗ Department of Neurology, University of Oklahoma, 825 NE 10th Street, Suite 5200, Oklahoma City, OK 73104-5021, USA
a r t i c l e
i n f o
Article history: Received 26 March 2013
Keywords: Migraine in older adults Elderly headache Cervicogenic headache Late-life migraine accompaniment Medication overuse headache Abdominal migraine
a b s t r a c t Migraine in an older person may appear with sensory or motor phenomena (“late-life migraine accompaniments”), so that it may be confused with transient ischemic attack or stroke. An older patient may have cervicogenic headache in addition to migraine. Medication overuse headache is just as much of a problem in older patients as it is in younger ones. Abdominal migraine without headache can be seen in older adults as a migraine equivalent, just as it can occur in children. The most effective drugs for migraine prophylaxis in young people (divalproex, topiramate, metoprolol and propranolol) are similarly effective for those who are over the age of 50. Oral rescue drugs, including naproxen and hydroxyzine, are also useful in older adults. We need to remind older adults about the dangers of excessive use of caffeine in coffee, tea and energy drinks, since these substances can lead to daily HA and migraine equivalents. © 2013 The Authors. Published by Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Case 1 vignette: late-life migraine accompaniment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1. Diagnosis of late-life migraine accompaniment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.2. Management of late-life migraine accompaniment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Case 2 vignette: cervicogenic headache and migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.1. Diagnosis of cervicogenic headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2. Management of cervicogenic headache and migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Case 3 vignette: medication overuse headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3.1. Diagnosis of medication overuse headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3.2. Management of medication overuse headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Case 4 vignette: abdominal migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.1. Diagnosis of abdominal migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.2. Management of abdominal migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Frequent headaches (HA) are seen in about 17% of those over the age of 65, according to one large epidemiologic study [1].
夽 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. ∗ Corresponding author. Tel.: +1 405 271 4113; fax: +1 405 271 2523. E-mail address: [email protected] (L.A. Hershey).
Others have reported the frequency of HA in the elderly to be as high as 50% [2], or as low as 12% [3]. The prevalence of migraine increases from age 12 to age 40, but in the 50–59-year cohort of the American Migraine Study, it still affected 20% of women and 7% of men [4]. Pascual and Berciano [3] found that serious conditions such as ischemic and hemorrhagic stroke, temporal arteritis, post-concussive HA, or intracranial neoplasm were more likely to be present in elderly patients who complain of HA (15%, compared to 1.6% of patients under the age of 65). Medications may be the cause of HA in as many as 8% of patients who present with HA [5]. Chronic daily HA is another group of patients that includes
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those with transformed migraine, chronic tension HA and hemicrania continua [6]. Medication overuse headache (MOH), a disorder that can result from the chronic overuse of analgesics, triptans, caffeine, or other HA remedies, has a prevalence of about 1–2% among those who are over the age of 65 [7]. Abdominal migraine, which is more common in those with a family history of migraine HA, usually emerges between the ages of 3 and 10 years, and rarely persists into adulthood [8]. We present here a case with onset over 50.
without aura. She had a past medical history of hypertension, cervical spine disease and chronic daily HA. The HAs were usually right-sided and worsened significantly with certain repositioning maneuvers of the neck. She had trigger points bilaterally in the trapezius, sternocleidomastoid, and suboccipital musculature. There was limitation of range of motion of the head and neck in all planes of movement. Otherwise, her neurologic exam was nonfocal.
2. Methods
2.1. Case 1 vignette: late-life migraine accompaniment
2.2.1. Diagnosis of cervicogenic headache Cervicogenic HA is characterized by chronic continuous unilateral HA and neck pain that is exacerbated by neck movement, or sustained awkward head position [14]. Abolition of the HA with anesthetic blocks of various cervical nerve roots provides supportive evidence that the pain is attributable to the cervical spine disorder. In one recent epidemiologic study, 42% of those with cervicogenic HA had the co-occurrence of migraine [14], similar to our patient.
This 51-year-old right-handed woman had a previous history of hypertension and migraine. She arrived in the emergency room (ER) with the chief complaints of nausea, vomiting, vertigo, weakness of the right face and traveling paresthesias up and down her left arm. She had been having HAs off and on for the last few weeks, but she did not have HA at the time of this ER visit. Her examination was remarkable for high blood pressure (177/94), right ptosis, diminished sensation over the right side of the body, an upgoing right toe, but no weakness over the right face or right body. By the second day, all her symptoms and signs had resolved, except for subjective vertigo. The diffusion weighted image sequences of the MRI scan showed no signs of a new cerebral infarction.
2.2.2. Management of cervicogenic headache and migraine We started our patient on naproxen 500 mg every 12 h as needed for abortive therapy. Topiramate 25 mg twice daily was given for migraine prophylaxis. Weekly physical therapy sessions were initiated for treatment of the patient’s neck pain. After four months, the HA completely subsided, and the neck pain and range of motion improved. A multidisciplinary team approach for HA management, including physical therapy, has been shown to be effective in reducing the occurrence of a variety of HA syndromes [15]. Another treatment for cervicogenic HA includes blockage of the greater occipital nerve with a mixture of xylocaine and marcaine [14].
2.1.1. Diagnosis of late-life migraine accompaniment In his first series of 120 late-life migraine accompaniments, Fisher [9] made the point that HA occurred in only 50% of the cases. In his second series, he reported that the patients ranged in age from 40 to 73 years (the same ages as those who commonly have cerebrovascular disease), but that the traveling paresthesias of migraine were different from the pattern of paresthesias seen in those with transient ischemic attacks and strokes [10]. The spreading depression of migraine [11] is the best explanation for the “march” of paresthesias in late-life migraine accompaniments. Forty percent of patients with migraine accompaniments in Fisher’s second series had HAs [10]. This fits with our patient, who did not have HA at the time of her admission, even though she had a history of migraine, in addition to drug-overuse HAs.
2.3. Case 3 vignette: medication overuse headache
A literature search was performed for papers published up until December, 2012, using the reference database pubMed. The key words were as follows: migraine in older adults, elderly HA, latelife migraine accompaniment, cervicogenic HA, medication overuse HA, abdominal migraine in adults.
2.1.2. Management of late-life migraine accompaniment We started our patient on topiramate for HA prophylaxis, since it is one of several drugs that are recommended by the Quality Standards Subcommittee of the American Academy of Neurology for migraine prophylaxis [12]. Other Level A drugs that prevent migraine include divalproex sodium, metoprolol, and propranolol. Level A drugs are those that have been shown to be effective in at least two Class 1 clinical trials. This patient was also counseled against daily use of over-the-counter analgesic medications, since medication overuse is a common cause of chronic daily HA in older adults [7,13]. She was also counseled against the use of caffeine, since this can lead to daily HA [7]. 2.2. Case 2 vignette: cervicogenic headache and migraine This 54-year-old right-handed woman had a strong family history of migraine HA and a personal history of migraine with and
This 67-year-old right-handed woman had a strong family history of migraine HA and a personal history of migraine HA with and without visual aura since the age of 13. She had a past medical history that was positive for diverticulitis, gastroesophageal reflux disease, gastritis, chronic diarrhea, and osteoarthritis. She came to the clinic with the complaint of chronic daily HA. An MRI had been performed a few years ago and was normal. She had been using a butalbital preparation daily since 1976. Her HAs had become steadily more severe and more frequent since that time. Now her HAs were occurring on a daily basis. She was not awakened at night with the HAs, and they were not worse when lying down. She denied jaw pain, snoring, or bruxism. Her neurologic examination was unremarkable. The ESR was normal. She denied excessive use of caffeine, tea, or energy drinks. 2.3.1. Diagnosis of medication overuse headache Migraine is a common disorder that usually begins in adolescence or young adulthood, as it did in this patient. Episodic migraine is defined as occurring fewer than 15 days a month [16]. Medication overuse HA (MOH) is defined when HA occurs on 15 or more days per month, when the therapeutic agent is used excessively, and when it is used on a regular basis for three or more months prior to the worsening of the HA frequency and severity [17]. MOH can result from the overuse of analgesics, triptans, barbiturates, caffeine, or other drugs that are used acutely to manage HA [7]. Triptan overuse can produce MOH at a faster rate and with lower doses than butalbital or narcotics [17]. The prevalence rates of MOH (1–2%) are similar across different countries, and the mean age of onset is 53 [18]. There is a higher preponderance of women with MOH (74%) than men (26%). Among those who were over the age of
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65, the prevalence of MOH in Taiwan was 1% [19] and in Italy was 1.7% [13]. 2.3.2. Management of medication overuse headache This woman was educated about both pharmacologic and nonpharmacologic HA treatment strategies. She was given a tapering dose of phenobarbital to replace the butalbital (30 mg/day of phenobarbital for every 100 mg/day of butalbital). The phenobarbital was tapered by 15 mg every 7 days until it was discontinued. In addition, divalproex was started for HA prophylaxis at a dose of 125 mg bid. When she came for her followup visit at one month, she was HA-free. Relapse rates for MOH vary from 14% to 41% at 12 months [7]. We often give hydroxyzine 25–50 mg q6 h to MOH patients in case they have breakthrough HA while they are being tapered from the overused analgesic medication. If this patient had not benefitted from this dose of divalproex, the dose could have been increased to 250 mg bid, or even 500 mg bid. Another helpful prophylactic HA treatment for MOH patients is topiramate [20]. The benefit of topiramate for MOH has been supported by several randomized clinical trials. We encourage our MOH patients to keep a HA calendar, so that HA frequency, severity and doses of rescue therapies can be closely monitored. 2.4. Case 4 vignette: abdominal migraine This 59-year-old left-handed man with a history of hypertension, nephrolithiasis, diverticulosis and esophagitis was referred to neurology clinic because of prolonged bouts of abdominal pain of unknown etiology. His mother had had migraine HA, and he himself had 1–2 non-migrainous HAs per year. He first began having the abdominal pain at the age of 52, which was characterized by sharp, constant pain in the left lower quadrant, lasting from hours at a time to months. The pain was not associated with meals, or with the time of day. Suboxone and hydrocodone were the only medications that relieved the pain. The extensive gastroenterology workup was completely negative. His neurologic exam was negative. 2.4.1. Diagnosis of abdominal migraine In pediatric populations, the most common migraine equivalent is benign positional vertigo, followed by abdominal migraine [21]. There is usually a family history of migraine HA in those who have abdominal migraine, as there was in our patient. Abdominal migraine often occurs in close temporal proximity to migraine HA and includes a myriad of symptoms, including abdominal pain, nausea, gas, bloating, loose stools, or constipation. There was recently a young adult case of abdominal migraine described in the literature, but she differed from our patient in that she had concomitant migraine HA [21]. The prognosis of abdominal migraine of childhood is usually benign, since remission usually occurs in two years. 2.4.2. Management of abdominal migraine Our patient was started on divalproex 125 mg twice daily, and after several weeks, he experienced significant decrease in his abdominal complaints. At his last appointment, he had been asymptomatic for one month. If he had not had kidney stones in the past, we could have treated him with topiramate. Other drugs that have been shown to be helpful for treating patients with abdominal migraine include flunarizine, propranolol and cyproheptadine [8,21]. 3. Conclusions Migraine in older patients may present as migraine accompaniments, where the symptoms seem more like transient ischemic
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attacks, rather than HA. These symptoms are best treated with the usual migraine prophylactic medications. Patients with migraine who have cervicogenic HA in addition to migraine are best treated with physical therapy, or nerve blocking agents, in addition to their usual migraine prophylactic medications. MOH commonly begins over the age of 50, after many years of using analgesics or other acute migraine therapies, such as triptans or butalbital. MOH is best treated by discontinuing the offending medication and starting a migraine prophylactic agent in its place. Abdominal migraine is another form of migraine equivalent. It is best treated with the usual migraine prophylactic medications. Contributors Brett Dees, Rhonda Coleman-Jackson and Linda A. Hershey are the sole contributors. Competing interest The authors have no competing interests. Provenance and peer review Commissioned and externally peer reviewed. Funding No funding issues. References [1] Cook N, Evans DA, Funkenstein H, et al. Correlates of headache in a population-based cohort of elderly. Archives of Neurology 1989;46: 1338–44. [2] Hale WE, May FE, Marks RG, Moore MT, Steward RB. Headache in the elderly: an evaluation of risk factors. Headache 1987;27: 272–6. [3] Pasqual J, Berciano J. Experience in the diagnosis of headaches that start in elderly people. Journal of Neurology, Neurosurgery and Psychiatry 1994;57:1255–7. [4] Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001;41:646–57. [5] Lipton R, Bigal M, Steiner T, Silberstein S, Olesen J. Classification of the primary headaches. Neurology 2004;63:427–35. [6] Castillo J, Munoz P, Guitera V, Pasqual J. Epidemiology of chronic daily headache in the general population. Headache 1999;39:190–6. [7] Evers S, Marziniak M. Clinical features, pathophysiology, and treatment of medication-overuse headache. Lancet Neurology 2010;9: 391–401. [8] Carson L, Lewis D, Tsou M, et al. Abdominal migraine: an underdiagnosed cause of recurrent abdominal pain in children. Headache 2011;51: 707–12. [9] Fisher CM. Late-life migraine accompaniments as a cause of unexplained transient ischemic attacks. Canadian Journal of Neurological Sciences 1980;7: 9–17. [10] Fisher CM. Late-life migraine accompaniments—further experience. Stroke 1986;17:1033–42. [11] Lauritzen M. Pathophysiology of the migraine aura. The spreading depression theory. Brain 1994;117:199–210. [12] Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Neurology 2012;78: 1337–45. [13] Prencipe M, Casini AR, Ferretti C, et al. Prevalence of headache in an elderly population: attack frequency, disability, and use of medication. Journal of Neurology, Neurosurgery and Psychiatry 2001;70: 377–81. [14] Knackstedt H, Bansevicius D, Aaseth K, et al. Cervicogenic headache in the general population: the Akershus study of chronic headache. Cephalalgia 2010;30:1468–76. [15] Wallasch TM, Angeli A, Kropp P. Outcomes of a headache-specific cross-sectional multidisciplinary treatment program. Headache 2012;52: 1094–105.
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[16] Buse DC, Manack AN, Fanning KM, et al. Chronic migraine prevalence, disability, and sociodemographic factors: results from the American Migraine Prevalence and Prevention Study. Headache 2012;52:1456–70. [17] DeFelice M, Ossipov MH, Porreca F. Update on medication-overuse headache. Current Pain and Headache Reports 2011;15:79–83. [18] Straube A, Pfaffenrath V, Ladwig KH, et al. Prevalence of chronic migraine and medication overuse headache in Germany – the German DMKG headache study. Cephalalgia 2009;30:207–13. ISSN 0333-1024.
[19] Wang SJ, Fuh JL, Lu SR, et al. Chronic daily headache in Chinese elderly: prevalence, risk factors, and biannual follow-up. Neurology 2000;54: 314–9. [20] Russell MB, Lundqvist C. Prevention and management of medication overuse headache. Current Opinion in Neurology 2012;25:290–5. [21] d’Onofrio F, Cologno D, Buzzi MG, et al. Adult abdominal migraine: a new syndrome or sporadic feature of migraine headache? A case report. European Journal of Neurology 2006;13:85–8.