September/October 2018

Crack the Migraine Mystery: It's Not Just a Headache
By Amaal Starling, MD
Today's Geriatric Medicine
Vol. 11 No. 5 P. 26

Most clinicians have treated or tried to treat patients living with migraine, a debilitating neurological disease affecting more than 38 million Americans of all ages.1 However, for various reasons, treating migraine is not a straightforward proposition, and for older adults who suffer, there are additional variables.

As providers, we know that a migraine attack is more complex than a simple headache, especially for those who experience migraine attacks later in life. Though the incidence of migraine is highest in midlife (ie, between ages 25 through 50), approximately one-third of migraine patients continue to experience migraine attacks as older adults. And a small number (2% to 3%) may experience their first migraine attack after age 50.2

Primary Challenges to Diagnosis
Despite being more common than diabetes3 or asthma4 in the United States, migraine is often misunderstood by patients who may assume "it's just a headache" and that they have to deal with it on their own. In fact, only one in every three people who experiences a migraine attack actually talk to their doctor about their symptoms, and only one-half of those individuals are diagnosed properly.5

Most often, migraine is misdiagnosed for a tension-type or sinus headache, and as a result, some patients are not provided with the appropriate treatment regimen to achieve relief.6 And, unfortunately, when left untreated, migraine attacks can cause significant pain and other symptoms lasting for hours to days and can be so severe that the symptoms are disabling, leaving people unable to work or function in day-to-day living.5,7

When visiting with a patient, defining migraine, especially vs a tension-type or sinus headache, is helpful to reaching a proper diagnosis. With better understanding, it's our hope that patients can better communicate their symptoms in detail to help them down the right treatment path .

Headache is pain in any region of the head—one or both sides of the head, isolated to a certain location, or radiating across the head from one point) and may appear as a sharp pain, a throbbing sensation, or a dull ache.8

Migraine is a neurologic disease characterized by recurrent, severe attacks of head pain (sometimes specific to one side of the head, but sometimes on both sides) and other associated symptoms such as nausea and/or vomiting and sensitivity to light and sound. In some cases, patients may experience aura, which include temporary visual, sensory, or language disturbances that occur before head pain and other migraine symptoms. Visual aura signs include having blind spots, seeing spots or flashing lights, or having a temporary block of vision.

Other aura disturbances include numbness or tingling in the face or body and difficulty with speech or language.7,9

Adult patients with migraine who are under 50 years of age almost always experience severe head pain along with one or more of the associated symptoms noted above. But for those experiencing late-life migraine attacks, proper diagnosis becomes that much more challenging, as pain is not always the primary symptom.10,11 Instead, those with late-life migraine attacks, who often reside in assisted living or another care setting, may experience the aura but not the head pain classically associated with migraine.

Aura without head pain or with minimal head pain can be a challenging diagnosis for clinicians (including those who work in a long term care setting) because new onset focal neurologic symptoms in the older adult may be a sign of a cerebrovascular ischemic event.12,13 Due to the morbidity and mortality associated with cerebrovascular disease, a stroke or transient ischemic attack must first be considered, worked up, and ruled out. Once a workup for a cerebrovascular ischemic event has been completed and is negative, migraine aura without headache can be considered as a diagnosis in the older adult, especially in patients with a history of migraine.

The Comorbidity Factor
Comorbidities are important to consider in the management of migraine, especially in the older adult. Comorbid illnesses common in older adults with migraine include coronary heart disease, hypertension, movement disorders such as restless legs syndrome, and psychiatric diseases such as depression, anxiety, bipolar disorder, and panic disorder.14

For example, consider Esther, a 72-year-old female with a history of high blood pressure, high cholesterol, diabetes, atrial fibrillation, and peptic ulcer disease who has been more withdrawn over the last six months in her long term care facility. Upon questioning, she reports poor sleep, poor appetite, daily headaches, and neck pain. A detailed headache history reveals bilateral moderate-intensity headache and neck pain attacks, worsened with walking. She feels better when she can go lie down in a cool, dark, quiet room.

Esther's headache and neck pain attacks meet diagnostic criteria for migraine, although at first glance one might conclude that she suffers from depression because she's been more "withdrawn." But she's withdrawing from activity because it hurts to participate and her migraine attacks have disabled her. Unfortunately, treatment will be challenging due to her medical comorbidities.

The Treatment Puzzle: Medication and More
Providers, particularly those who work with older patient populations, must tailor treatment plans based on what will provide safe and optimal relief to the patient. Currently, the main focus of migraine treatment is to reduce the frequency of attacks and the severity of the pain.15

For immediate pain relief, the most common first line treatment for "rescue" against onset of migraine attack are NSAIDs and triptans. However, NSAIDs are not recommended for individuals with cardiovascular or gastrointestinal diseases. Triptans are contraindicated in those with poorly controlled blood pressure, significant cardiovascular disease, or a history of a heart attack or stroke—common comorbidities in the older population. The use of opioid medications is not recommended for the treatment of migraine, especially in the older adult, due to sedation, cognitive impairment, respiratory depression, and physical dependence.

What does that leave? For older migraine patients, acute options are limited, especially when comorbidities are present.11 In this setting, the focus is on prevention, even when attacks are infrequent.

Preventing Attacks
Prevention is key when migraine attacks are debilitating and frequent (occurring more than once a week) and when acute medications are poorly tolerated, contraindicated, or ineffective. Currently available preventive treatment options in migraine are not disease specific or mechanism based. They were designed for other disease states, such as high blood pressure, depression, and epilepsy. However, clinical trials have demonstrated that these medications are more effective than placebo in migraine prevention.

Unfortunately, these medications may have side effects that can be problematic for any patient, especially the older adult. Some concerning side effects specifically for the older adult include low blood pressure, insomnia, depression, urinary retention, dry mouth, constipation, changes in heart rhythm, and cognitive impairment.

Accessing Medications
After factoring in symptom presentation and comorbidities, the clinician must determine what treatments are readily available to their patients. As is commonplace in medicine today, dollars and cents play a role in prescribing, as do insurance companies (and those they negotiate with, including pharmacy benefit managers and manufacturers).

For migraine, onabotulinumtoxinA (Botox) has been shown to be helpful in the prevention of chronic migraine, defined as experiencing more than 15 headache days per month with at least eight days with migraine features.16 However, in my practice, due to insurance requirements, many younger (<65 years) patients are required to first fail other less expensive preventive treatment options before being able to try this more expensive option. Notably, Medicare will cover the medication, provided patients meet criteria for chronic migraine.

Patients can stay up to date on access issues related to migraine at www.50statenetwork.org.

A treatment plan cannot be complete without including lifestyle recommendations,17 which may not cost the patients a dime or result in side effects. In long term care, preventive migraine management can include promoting sleep hygiene, consistently healthful meals, weekly exercise, adequate fluids to prevent dehydration, and stress management. Older adults should be reminded about common migraine triggers, including too much caffeine in coffee, tea, and energy drinks. Encouraging patients to track their symptoms with a headache diary can help gauge which parts of their plans are working and which may need adjustment.

Keep Relief Top of Mind
While current treatment remedies focus on achieving acute relief, migraine prevention is the ultimate (and long overdue) goal for providers and patients alike. Providers are keeping a close eye on late stage research surrounding a new class of investigational treatments referred to as anti-CGRPs, or CGRP (calcitonin gene-related peptide) inhibitors, as these medications would be the first specifically designed to prevent migraine.

Findings from Phase 3 trials give reason for excitement as these potential treatments may provide options that are better tolerated with no reported safety issues.18 Notably, the first in the class were approved in May 2018. But as seen with Botox, patients who are approved to receive them can expect these treatments to be more expensive than currently available medications with or without insurance, and providers will need to stay prepared to work with patients to help them gain access, if they are appropriate for their use.

Migraine is not just a headache. It's a complex neurologic disease affecting millions of older adults. It's vital that health care professionals caring for these patients, such as health aides, nurses, and doctors, understand the variety of symptoms so that effective treatment and management plans can be crafted to prevent disability.

— Amaal Starling, MD, is an assistant professor of neurology in the Mayo Clinic College of Medicine in Arizona.

References
1. Migraine facts. Migraine Research Foundation website. http://migraineresearchfoundation.org/
about-migraine/migraine-facts/. Accessed April 30, 2018.

2. Capobianco DJ. Headache in the elderly. Adv Stud Med. 2003;3(6C):S556-S561.

3. Centers for Disease Control and Prevention. National diabetes statistics report, 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed April 30, 2018.

4. Asthma. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/fastats/asthma.htm. Updated March 31, 2017. Accessed April 30, 2018.

5. Living with migraine. American Migraine Foundation website. https://americanmigrainefoundation.org/living-with-migraines/. Accessed April 30, 2018.

6. Al-Hashel JY, Ahmed SF, Alroughani R, Goadsby PJ. Migraine misdiagnosis as a sinusitis, a delay that can last for many years. J Headache Pain. 2013;14(1):97.

7. Migraine. Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201. Accessed April 30, 2018.

8. Headache definition. Mayo Clinic website. https://www.mayoclinic.org/symptoms/headache/
basics/definition/sym-20050800. Updated January 11, 2018. Accessed April 30, 2018.

9. Migraine with aura. Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/migraine-with-aura/symptoms-causes/syc-20352072. Accessed April 30, 2018.

10. Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5):343-349.

11. Hershey LA, Bednarczyk EM. Treatment of headache in the elderly. Curr Treat Options Neurol. 2013;15(1):56-62.

12. Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: a narrative review. Cephalagia. 2015;35(10):894-911.

13. Dees B, Coleman-Jackson R, Hershey LA. Managing migraine and other headache syndromes in those over 50. Maturitas. 2013;76(3):243-246.

14. Wang SJ, Chen PK, Fuh JL. Comorbidities of migraine. Front Neurol. 2010;1:16.

15. Treatment options. American Migraine Foundation website. https://americanmigrainefoundation.org/treatment-options/. Accessed April 30, 2018.

16. Escher CM, Paracka L, Dressler D, Kollewe K. Botulinum toxin in the management of chronic migraine: clinical evidence and experience. Ther Adv Neurol Disord. 2017;10(2):127-135.

17. Non-pharmacologic treatments. American Migraine Foundation website. https://americanmigrainefoundation.org/understanding-migraine-cat/non-pharmacologic-treatments/. Accessed May 4, 2018.

18. Tso A, Goadsby P. Anti-CGRP monoclonal antibodies: the next era of migraine prevention. Curr Treat Options Neurol. 2017;19(8):27.