Migraine in later life
Migraine can improve with age, but unfortunately this is not the case for everyone
We often hear from migraine sufferers that they expected their migraine attacks to get better as they got older. Unfortunately this is not the case for everyone and there are many people with migraine in their 60s, 70s, and 80s. Here we look at the key questions about migraine in older age.
Migraine and age
Migraine often occurs for the first time in your teens or early 20s. It is most common in the 30 to 40 age group. At least 90% of people with migraine experience a first attack before the age of 40. Generally it is true that migraine improves as we get into our 50s and 60s. Studies show 40% of people with migraine no longer have attacks by the age of 65. Before the menopause, three times as many women as men have migraine. After 60, when hormonal factors are less likely to play a role, twice as many women as men have migraine.
It is therefore reasonable to expect your migraines to get better as you get older, however, the total number of people with migraine in later life is considerable in many populations worldwide.
Can migraine occur for the first time in later life?
It is rare, but not impossible, for migraine to occur for the first time later in life. If new migraine-like symptoms develop for people over 60, underlying disease may be responsible. In a study of older patients with new migraine-like headaches, five out of 69 patients had an abnormality which showed on a scan. Doctors will be cautious when considering a new diagnosis of migraine for a person over 60.
Can migraine symptoms change over time?
Migraine symptoms can change throughout a person’s lifetime. Attacks of migraine aura without development of headache are relatively common as migraine sufferers get older. Pain may not be as severe, symptoms may be less intense, or attacks may reduce in frequency. It is possible to have attacks in your teens or twenties, which return after years of being migraine free. This is less likely to be of concern than headaches starting for the first time, or if symptoms begin to change a great deal.
What if you have more than one health condition?
As we age, the likelihood of developing medical conditions increases, sometimes with implications for migraine treatment. Conditions such as hardening of the arteries (atherosclerosis), high blood pressure, diabetes, heart disease or stroke, may have implications for the management of migraine. In addition, having another health condition can be an additional trigger for migraine, whilst treating the co-existing health condition may help reduce migraine attacks. Some frequently asked questions are about migraine and stroke, depression, cognition, vertigo or epilepsy.
Migraine and other conditions
Migraine and stroke
Migraine, especially with aura, has been found to be a small risk for ischaemic stroke (that is, stroke due to a reduced blood supply sometimes due to a clot) in women under 35 though not haemorrhagic stroke (where a damaged or weakened artery bleeds into nearby tissue). However, migraine is not more common in older people who have had an ischaemic stroke. One study has suggested a higher cardiovascular risk profile in people with migraine, particularly with aura, than those without migraine. A study presented at the American Academy of Neurology 60th Annual Meeting in 2008 followed 27,840 women over the age of 45 years for an average of 11.9 years and showed no increased risk for any form of heart disease or stroke in most migraine patients. The risk is thought to be relevant only to women with migraine with aura and the majority of people with migraine have migraine without aura. However, although these data provide support, as do previous studies, for an association between migraine aura and ischaemic stroke, it is not possible to make any strong inference in the absence of more detailed research.
Migraine is considered to be insignificant as a risk for stroke over the age of 50, compared to more important age-related factors. It is important that everyone over 45 remembers that a sensible diet, good blood pressure control and not smoking are worth the effort as they are all risk factors that can be controlled for heart disease and stroke.
Migraine and depression
People with migraine are more likely to have depression. A large Swedish study published in 2002 showed that women aged 60-74 years were more likely to continue to experience migraine if they had also had major depression in the past. People who have had depression at any time in their lives are more likely to continue to have migraine attacks in older age.
Migraine and cognition
Migraine causes significant and often frequent disruptions of the physiology of the brain and there is a higher incidence of brain lesions in people with migraine with aura (though this does not seem to have a clinical consequence). Some people worry that this will eventually cause cognitive decline (meaning decline in reasoning or problem solving). However studies have failed to find a relationship between migraine and cognitive decline. Even a long history of severe migraine does not seem to impair cognition. It is very unlikely that migraine and cognitive impairment in older people are related.
Migraine and vertigo
There is evidence to suggest a condition related to migraine called ‘migraine–related vertigo’ or ‘migrainous vertigo’. In this condition, a person with migraine experiences a sensation of spinning or turning that interferes with daily life. Usually, the onset of this type of vertigo is delayed beyond the start of migraine symptoms, by months or years. Dizziness is a common complaint and seems to increase with age. However the occurrence of migraine-related vertigo is most common in the 40s in men and between the 30s and 40s in women.
People with Meniere’s disease more often have migraine than people without Meniere’s disease. About half of people with Meniere’s disease experience attacks of dizziness with migraine-like symptoms. Often, migraine symptoms will have been experienced for some time – sometimes up to 30 years or more – before the onset of Meniere’s disease.
Migraine and epilepsy
There has been little research carried out so far concerning older people who have both migraine and epilepsy. For those who have both conditions, it may influence the choice of preventative migraine treatment, as some medicines can treat both conditions.
Managing your migraine
As with migraine experienced at any age, it is always worth being aware of what may be triggering your migraines and taking steps to reduce your exposure to these triggers where possible. Trigger factors can change over time and new triggers may be discovered if your circumstances change. Stress and red wine may be implicated at times whereas neck and back problems, and other health conditions, may be more significant at other times.
If you visit a health professional for advice in managing your migraine, it is very useful to keep a migraine diary before the appointment and take this along. You can simply block out days in different colours to distinguish migraine days, other headache days and headache-free days. This helps to show the pattern of symptoms and is useful for your doctor. You can also use migraine diaries to identify trigger factors although this is not always easy. It is thought that people with migraine have a more than usually sensitive nervous system that reacts to factors to which you are sensitive. Frequently mentioned migraine trigger factors include: hunger, bright or flickering light, stress and changes of routine. Almost any factor can trigger an attack in a person predisposed to migraine and the list of possible suspects can be long and confusing. However it is worth persevering as reducing your exposure to your personal trigger factors can mean you are less vulnerable to a migraine attack.
Treatment for migraine in later life
Treatment of migraine may not be straightforward in older age. That may be due to taking a number of different medications or having more than one health condition.
Health professionals have less information to rely on when prescribing medication for migraine in older people. Drug trials are usually carried out on healthy young adults so often less is known about how a drug may work or react in a child or an older person. This can reduce the number of treatment options available. Your doctor will need to take into consideration any other health conditions you may have and medications you might already be taking.
Make sure that your doctor knows what medication you are currently taking, including over the counter treatments and herbal remedies, especially if you are starting new medication.
The likelihood of side effects from medication can increase during older age. Getting older involves several changes that together alter the responses to medicines. These include changes to the digestion, liver, kidneys and vascular system. As we get older we are more likely to experience side effects from drugs. The significance of a particular side effect can change. For example if a drug has a side effect of dizziness, this could be of more concern to a person who may also be at risk of falling, than another younger person for whom the same side effect may not be as serious.
Medication taken for other health problems can cause headaches as a side effect, and this is often an unrecognised cause of headaches in older people. Drugs with the potential to trigger headaches include those used to treat certain heart conditions. Some drugs used for high blood pressure can worsen headaches, but others, such as beta blockers, can treat both. Be aware also that drugs may interact causing unwanted side effects or reduced efficacy. If you find your headaches increasing and you take several different drugs for medical conditions other than headache, it is worth checking with your doctor or pharmacist whether these medicines are a possible cause of some of your headaches.
Migraine medicines for older people
A recent review of migraine treatments for older patients provided the following information for doctors. Where a drug is used ‘with caution’, the medicine having been prescribed by a doctor, its use needs to be monitored to ensure continuing safety.
Acute migraine drugs
Paracetamol can be used by older people with migraine, but your doctor may monitor liver function if you are taking it regularly in doses over 3 grams a day. If there are concerns about liver or kidney function, the dose may be reduced by 50 – 75%. Aspirin should be used with caution due to the risk of gastric ulcer or bleeding. Sometimes a painkilling drug will have caffeine added to increase effectiveness, this does not lead to increased side effects.
Non-steroidal anti-inflammatory drugs, such as ibuprofen and diclofenac, should be used with caution, if at all, by older people. Codeine, and other opiods, should be used with caution as they cause drowsiness and other side effects. If you use these medicines, your doctor will start with a low dose and increase the dose slowly until the lowest effective dose is found.
Medicines for sickness during migraine attacks such as metoclopramide can increase the possibility of side effects, called extrapyramidal side effects, such as involuntary movements or tremor.
Ergotamine should be avoided or used with caution because of its side effects.
Can I take triptans after 65?
One action of triptans is to constrict blood vessels so there is a concern that any diseased blood vessels may also be constricted, such as those in the heart.
As we age, blood vessels become narrower, and drugs that further narrow blood vessels should be avoided. Some people are more at risk than others, but it is not always easy to identify who may be affected. There is a general recommendation that those over 65 avoid taking triptans and this is largely based on a lack of systematic studies. It does not necessarily mean that you cannot take triptans. An older person should receive an evaluation for risk before triptans are prescribed.
Preventive drugs for migraine
These are some of the drugs you may be prescribed:
- Tricyclic antidepressants, such as amitriptyline and nortriptyline, should be used with caution. The doses used for migraine are lower than for treating depression so there is less likelihood of side effects. Nortriptyline is associated with fewer side effects
- Beta-blockers – use may be limited as they influence other medical problems and the dosage of propranolol needs to be altered from that taken by a younger person
- Sodium valproate – side effects are more common in older age
- Topiramate – risk of side effects in all ages
- Lisinopril and candesartan – sometimes prescribed for high blood pressure, should be used with caution as they can cause kidney problems
- Calcium channel blockers – dosage needs to be adjusted for older people as side effects are more common.
Sometimes a doctor will prescribe a course of preventative migraine drugs for people who have frequent attacks of migraine aura symptoms without subsequent development of headache.
Can migraine cause any long-term damage?
There is no firm evidence at present that having migraine will cause any permanent damage to your brain.
Headaches specific to later life
Headache is a common symptom and can occur at different times for many reasons. Headaches such as migraine and tension-type headache remain common at all ages. Some headaches are specific to older age.
Some severe and incapacitating headaches can mimic migraine but may be due to another health condition. If you have a new kind of headache occurring for the first time, always see your doctor, even if you have had migraine in the past.
The types of unusual headache include:
- Hypnic headache
This is a rare type of headache, which usually affects people over 50, called hypnic headache syndrome. Hypnic headaches occur exclusively at night, waking you from your sleep. The pain can be either on one or both sides of the head. The pain (sometimes described as throbbing) begins abruptly and typically lasts about 30-60 minutes.
It is more common amongst women than men. The pain is not associated with autonomic features (such as a blocked nose or watering eyes) like cluster headache, nor are nausea, and sensitivity to light and noise, usually associated with hypnic headache as they are with migraine. For more information about hypnic headache, The Migraine Trust has a separate fact sheet on this.
- Temporal arteritis
This condition is rare in young people, usually affecting those over the age of 50, particularly women. Its cause is unknown. In this condition, the arteries in the temples and elsewhere become inflamed and swollen. The arteries beneath the skin of the temples become painful, particularly when touched, and the skin over the artery becomes red. A headache is a symptom of temporal arteritis, the pain is on one or both sides of the head and is worse over the affected blood vessels. In some cases, chewing causes pain in the muscles of the jaw.
If you suspect that you may have temporal arteritis it is really important that you seek medical advice as an emergency. The disorder may affect blood vessels inside the head such as the temporal artery, which supplies the eye, and permanent blindness may result. Your doctor can do a simple blood test to help confirm the diagnosis. Occasionally it is necessary to take a small sample of the affected blood vessel. Steroids ease the pain rapidly and prevent blindness developing. This treatment needs to be continued for some time.
- Trigeminal neuralgia
Trigeminal neuralgia is more common in older people, affecting slightly more women than men. The pain is restricted to a nerve in the face, which causes sudden spasms of severe shooting pain in the cheek and jaw which last for only a few seconds. This spasm of pain is often described as being like an electric shock, and occurs in bouts every day for several weeks or months.
Triggers for this pain include chewing, cleaning your teeth, shaving and cold wind on your face. The condition is usually controlled with a drug called carbamazepine. A few people with trigeminal neuralgia do not get relief from the pain and may need surgical treatment.
Many people continue to have migraine attacks in older age. Special attention should be paid to the diagnosis of new migraine-like symptoms, especially visual migraine symptoms without headache. Any other co-existing health conditions have an important role not only in diagnosis but also in treatment choices. Acute and preventative medication should be chosen carefully. Effective treatment is available and, as for all age groups, careful management improves the quality of life.