Primary Headaches during aging: - PowerPoint Presentation

Slide1

Primary Headaches during aging:Migraine

Zahra Vahabi.MD

Assistant professor of neurology

Tehran University of Medical Science

2019

Slide2

Pain is a neglected issue in elderly

Slide3

Background There is a lack of detailed information about headache in elderly patients, particularly

new-onset

headache

.

Studies of the prevalence of headache have usually included only younger patients (<65 years) or only a few elderly patients

.

Clinical presentation of primary headaches is age dependent.

Slide4

Epidemiology of Headache

The prevalence of headache decreases with older age .

The characteristics of headache differ between elderly and younger patients.

Although 90% of headaches in younger patients are of the primary type, only 66% of those in the elderly are primary.

zahra vahabi

iran headache association

Slide5

zahra vahabi

iran headache association

Slide6

Secondary Headache In Geriatric

Sleep Apnea

Neoplasms

Subdural

hematomas

Head

trauma

Cerebrovascular

Disease

Temporal

Arteritis

Trigeminal

Neuralgia

Postherpetic

NeuralgiaMedication RelatedSystemic DiseaseParkinson’s DiseaseDiseases of the cranium, neck, eyes, ears, nose( Subacute Glaucoma)Exertional Headache due to Angina (Cardiac Cephalalgia)

zahra vahabi

iran headache association

Slide7

Primary headachesin

Geriatrics

Migraine

Tension

Cluster

Hypnic

zahra vahabi

iran headache association

Slide8

Migriane 2/3 of the patients the attack frequency decreases with age

In females about 20% of migraine patients lose their attacks per 10 years of life after the start of the menopause

Slide9

Primary headache : Migraine

Second most common primary headache

The annual prevalence of migraine over 65 years of age is approximately 10%

New onset migraine at age over 60 may be rare

New onset migraine in fifth decade was not uncommon

zahra vahabi

iran headache association

Slide10

Migraine

Migraine attacks were less typical in the elderly group.

Bilateral or global with decreasing associated features

including photophobia

,

phonophobia

, nausea, vomiting

Neck pain, bilateral rhinorrhea , lacrimation were notedzahra vahabi

iran headache association

Slide11

Migraine

Premonitory symptoms :

anorexia, paleness, and dry mouth were more common in the elderly

.

Neck

and occipital pain >> temporal pain. Greater ability to function during headache,

Good response to acute medication

zahra vahabi

iran

headache

association

Slide12

Migraine levels of VIP, SP, NPY, and CGRP,

in the middle cerebral artery decline with age

.

The

natural ageing of the brain causes changes in brain size, vasculature, and

cognition.

Trigemino

-thalamic pathways and other areas involved in migraine pathophysiology undergo degenerative or connectivity changes during ageing has yet to be investigated.

Slide13

Migraine In general, studies have shown an increased volume of white matter hyper intensities in elder migraine

patients.

Migraine

with aura was found to be associated with brain infarcts, in the absence of any cognitive impairment

.

Slide14

Late-life

migrainous

accompaniments

Migraine aura without headache can occur at any age and is

common

in elderly patients.

The largest case series of late-life migraine accompaniments were reported by Fisher (120 cases in 1980 and 85 cases in 1986, 205 cases in total).

Headache occurred in 50% of cases

zahra vahabi

iran headache association

Slide15

Classification of migrainous accompaniments Adapted from Fisher

Visual (excluding scintillating

scotoma

) 23%

Blindness

Homonymous

hemianopia

Blurred vision, difficulty focusing

Visual and

paresthesias

12%

Visual and speech

disturbance

4%Visual, paresthesias and speech disturbance 10%Visual, paresthesias, speech disturbance and paresis 5%Visual and brain stem symptoms 14%No visual accompaniments (only paresthesias, speechdisturbance, paresis, etc.) 30%zahra vahabiiran headache association

Slide16

Visual auras

Typical visual aura starts as flickering, uncolored, unilateral zigzag lines

,

beginning

centrally

in

visual

fields, it gradually builds up and progresses toward the periphery. Most visual auras last 15 to 30 min, with an average duration of 15 min. The most common visual symptoms are scintillation scotomas (fortification spectra, teichopsia), often bright and shimmering.

zahra vahabi

iran headache association

Slide17

Visual auras

Positive visual symptoms

: bright images , colored lights , and movement of images (90%)

Negative visual phenomena

: scotomas

,

blurred/foggy vision, and black dots/spots ( 50%).

The presence of both positive and negative features is the

hallmark

of visual aura.

zahra vahabi

iran headache association

Slide18

Sensory auras

Paresthesias

are the

second most common

migrainous

accompaniments (30%)

Most patients who have sensory aura also have visual aura .

Sensory auras include positive symptoms and negative symptoms .

zahra vahabi

iran headache association

Slide19

Sensory aurasCheiro-oral

(hand and face)distributions occur in

97%

of patients with sensory aura; the body and legs are rarely affected .

Slide20

Sensory aura

Typical

cheiro

-oral auras

were predominantly

unilateral

, starting in the hand, slowly spreading up to involve the forearm, and then migrating to the ipsilateral face, lips, chin, and tongue. Lower extremities are occasionally involved.

Sensory symptoms were bilateral in 50% of patients

. They last for 20 to 30 minutes and then clear in the reverse order (areas affected first, clear last) in 82%.

zahra vahabi

iran headache association

Slide21

Dysphasic auras

Aphasia, dysarthria, impaired production of language, and impaired comprehension of language.

Dysphasia is characterized by difficulty

finding words

, difficulty naming objects, and difficulty producing or understanding language.

Most patients with impaired production of language had

paraphasia

.

zahra vahabi

iran headache association

Slide22

Dysphasic aurasLanguage aura presented as

paraphasic

errors in 76%, other production problems in 72%, and impaired comprehension in 38% of cases .

Median duration of aphasic aura was

30 minutes

Slide23

Motor aura

weakness or paralysis can occur in late-life migraine patients and it is often associated with others accompaniments, most commonly visual and sensory auras .

Typical motor auras were characterized by unilateral location and frequently affected

hands and arms

in up to 90%.

zahra vahabi

iran headache association

Slide24

Diagnosis and differential diagnosis

TIAs

Seizures

Other potential differential diagnosis which can produce symptoms similar to migraine aura are

Cortical Subarachnoid

hemorrhage

,

cerebral amyloid angiopathy, AVM,

dural AVF,

patent foramen

ovale

,

posterior circulation embolism,

internal carotid and Vertebral artery dissection , carotid artery stenosis,

brain tumors.

zahra vahabiiran headache association

Slide25

TAI

Late-life migraine accompaniments and TIAs can be differentiated by

history and clinical features

.

A history of previous migraine attacks with aura

may be helpful, especially if prior aura features are similar to those experienced later in life.

zahra vahabi

iran headache association

Slide26

Migraine Migrainous auras :

G

radual onset

, evolve and expand over time,

S

equential accompaniments from one to another modality (visual, sensory, speech, motor) from one to another body part (e.g. hand then face), Repetitive stereotypic episodes

Slide27

Visual

Migraine aura

/

TIAs

Positive visual phenomena (bright)

/

Negative symptoms (loss of vision)

Involvement of both visual fields

/

Unilateral

Slowly moving across visual field

/

Static

15 to 60 minutes/ 3 to 10 minuteszahra vahabiiran headache association

Slide28

Sensory :

Gradual build-up evolution /

Abrupt onset

Positive phenomena (

paresthesia

) /

Negative symptoms (numbness)

Cheiro

-oral distribution (hand and face) /

Unilateral paresis

Repetitive attacks

/

Variable attacks

Sequential progression from one body part to another / Symptoms appear and disappear simultaneouslyArea involved first clear last /Flurry of stereotypic attacks not common 20 to 30 minutes/ 5 to 10 minuteszahra vahabiiran headache association

Slide29

Take Home Massage Take comprehensive historyDescribe to patients

Late life migraine and aura