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| This news site is not sanctioned by, nor part of, the Diamond Headache Foundation, The American Academy of Neurology OR The American Headache Society. |
| News covering selected sessions related to migraine from 2008 medical conferences. |
| Annual Meeting of the American Academy of Neurology |
Chicago, IL April 15-18, 2008 |
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Issues and Challenges Increase in Older
Headache Patients |
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BY DON SCHRADER
Contributing Writer |
CHICAGO
(ECCC)— Headache in older patients presents
hormonal and nonhormonal considerations that should be included
in the diagnosis and evaluation and addressed in clinical
management, Dr. Rob Cowan said on April 16 during the annual
meeting of the American Academy of Neurology.
Migraine prevalence increases in men during the second through
sixth decades but remains less prevalent compared with women,
said Dr. Cowan, a clinician and researcher at the Keeler Center
for the Study of Migraine in Ojai, Calif. Migraine also is
better characterized in women because of its associations with
hormone-related life stages and changes.
“In men, we don’t have a clear pattern, but there is a
prevalence that looks similar to that seen in women,” said Dr.
Cowan.
In older patients, examination of life stages and lifestyle
factors can be helpful to diagnosis and management of headache
syndromes. Factors that influence the natural history of
migraine in women include menarche, menses, contraceptives,
pregnancy, lactation, menopause, and hormone replacement. In men
the natural history influences are limited to puberty and
andropause, the emerging concept of changes in the aging male
analogous to those of menopause.
“Andropause is kind of a vague term. We don’t know when it
starts, when it stops, or what its significance is,” said Dr.
Cowan. “We have virtually no data on testosterone in andropause
as it relates to migraine.”
The migraine cycle in women usually begins in menarche and then
follows one of three courses: episodic until menopause, when it
usually disappears (most common); progression to chronic daily
headache; and flare or remit with pregnancy and worsening at
perimenopause.
Migraine prevalence is lower in spontaneously menopausal women
and greater in women who undergo surgical menopause. Women with
a history of premenstrual syndrome tend to have a higher
prevalence of migraine, whereas higher estrogen levels appear to
decrease the prevalence.
Examination of associations between sex hormones and migraine in
women have shown that progesterone delays menstruation but not
migraine, that estrogen delays migraine but not menstruation,
and that testosterone and androstenedione have no effect on
migraine.
Estrogen’s salutary effect on migraine can be traced to its
influence on various neurotransmitters, according to Dr. Cowan.
Estrogen increases serotonin and GABA, both of which are
headache inhibitory. Estrogen reduces levels of norepinephrine
and dopamine, which are headache promoting. Estrogen also
promotes autoanalgesia by stimulating the release of
β-endorphin.
Diagnosis of headache in older patients should devote careful
attention to distinguishing between primary and secondary
headache disorders.
“Just because a patient has a 40-year history of headache does
not mean that the patient has the same old headache,” said Dr.
Cowan. “You also have to be open to new diagnoses that may send
the patient to the emergency room.”
Comorbidities become more prominent in older age and should be
factored into the differential, he continued. Because older
patients tend to take more medications, clinicians should be
vigilant in monitoring for drug reactions and interactions.
Migraine rarely has an onset after age 50; however, the
presentation or characteristics of migraine can change with age,
most often evolving from common or classic migraine to
ophthalmic migraine associated with visual changes and aura
without headache. Secondary headache is more common in older
compared with younger patients.
Multiple types of comorbidites are associated with migraine in
older patients, including cardiovascular, respiratory,
gastrointestinal, neurologic, and psychiatric.
“Make a definitive diagnosis,” said Dr. Cowan. “Don’t just treat
the headache and assume it is a headache unto itself. That’s a
risky assumption in an older patient. Be sure to consider
comorbid conditions and confounding circumstances, including
changes in lifestyle and medications.”
“Regularly reassess the diagnosis, particularly if the patient
is not doing well,” he continued. “This is a time of life when a
lot of things change, both social circumstances and physiologic
circumstances. Medications and doctors increase exponentially.” |
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