Medical wisdom says that migraines reduce as people age - they are most common in the productive years and therefore migraine attacks should not be a

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1 Migraine at 65

2 Medical wisdom says that migraines reduce as people age - they are most common in the productive years and therefore migraine attacks should not be a major problem in later life. Studies show 40% of people with migraine no longer have attacks by the age of 65 years and at least 90% of people with migraine experience a first attack before the age of 40 years. To gain a better understanding, Migraine Action conducted a members survey. The results are not only very interesting but are somewhat surprising: Two thirds of respondents reported that their migraine has not improved since reaching 65 years. Half of the people who stated that their migraine had not improved also went on to say that it had actually worsened after they reached the age of 65 years. This is in direct contrast to the view that migraines get better with age and highlights the substantial number of older individuals in need of help and support for their migraine. How does migraine affect the over 65s? The survey went on to show that for those individuals whose migraine got worse, the frequency, pain, symptoms and / or duration of their migraine increased. For some, the intensity of their attacks decreased but the frequency increased and for others visual disturbance became more prevalent. For those whose migraines improved, the key aspect was that the frequency of their attacks greatly reduced.

3 Migraine medication is still much needed The survey clearly showed that in this age group, medication is still vitally important. With most people having experienced migraine for years, respondents stated that they were able to better understand what treatments and medications worked for them, and they used medication effectively when required. 75% of people continue with prescribed medication from their GP. Two thirds of the survey group stated that their medication was effective or very effective. The majority of people use a triptan as part of their migraine management plan, with others using over-the-counter options and prescribed preventative medication. Improvements to migraine sometimes came as a result of medications or treatments given for other medical conditions, such as blood pressure and heart conditions, and in some cases attacks drastically reduced or completely disappeared. Although many continue to rely upon, and benefit from, prescribed medication, concerns were voiced about medications being stopped after reaching 65 years, and about the lack of research that has been done into the effect of medication in this age group. Managing migraine: with age comes wisdom Respondents told us that having experienced migraines for a considerable period, not only did they gain an enhanced understanding of what treatments and medications work but are better at general migraine management, including the ability to identify triggers, with stress given as a major cause of an attack. The survey group stated that by making lifestyle changes and by taking control of their migraine, they were in a better position to manage the condition and cope with daily life. The role of complementary therapies 70% of our respondents have tried one or more complementary therapies as part of their migraine management. However, the benefits of the therapies tried gave mixed results. Acupuncture, relaxation treatments and herbal and vitamin supplements had the greatest benefits, but the general consensus was that complementary treatments may work in the short term but that no real sustained benefit was given.

4 Dr Manuela Fontebasso, a GP with a special interest in migraine, gives a doctor s perspective on why many feel it inappropriate to prescribe medicines, especially the triptan family, to the over 65s. Migraine can always be a challenge to treat. Finding the right drug or drug combination, at any age, can take time, patience and may feel like trial and error rather than a series of evidenced based decisions. In those under 18 years and over 65 years of age the choices can be restricted significantly as a result of the way the triptans class of medicines (Imigran, Zomig etc.) can, or rather cannot, be prescribed. Triptans have been available as a class of drugs for well over a decade and in all that time they have not been licensed for use under the age of 18 years and over the age of 65 years. Recently things have changed somewhat for those under 18 years (but over 12 years) with the availability of a sumatriptan adolescent nasal spray, but there have been no changes to the restrictions for those migraineurs over 65 years. I am often asked why this is the case. The answer lies in how drugs are licensed for use and therefore available for your GP to prescribe. Drugs are studied extensively in order to understand whether they work to treat an illness (in this case migraine), if they are safe to use, if they cause any side effects and, if so, what those side effects are. All the migraine studies for medicines being developed, have standard inclusion and exclusion criteria. The age restrictions mean that patients have to be over 18 years and under the age of 65 years. Once the studies are completed and it is felt that the drug is safe and effective, the research evidence is submitted for licensing approval. If the authorities approve the drug then it becomes available for GPs to prescribe on a prescription or FP10.

5 The GP uses a reference book called the British National Formulary (BNF) to check what drugs can be used to treat migraine. The BNF is the GP rule book and reflects the evidence used to decide whether or not it is safe to use a triptan for a particular patient. If you are 65 years or over, your GP will check the BNF and tell you that you cannot have triptans to treat your migraine. This is difficult to understand if you have been using a triptan for the last 10 years, especially if you have had no side effects. The rules state that you should no longer take a triptan because of concerns about the possibility of causing heart attacks and strokes. In some ways this is a theoretical risk because triptans might cause constriction of the arteries, and if there is atheroma or fatty deposits these might be released and cause blockage of a vessel. The older you are the greater the chance that you might have diseased blood vessels and as such are at higher risk of vascular problems. As a GP who has a special interest and experience in treating patients with migraine, I tend to sit and talk to patients about these risks. It becomes a decision of what I call informed consent. The individual needs to decide if the potential and theoretical risk is worth the benefit, and I need to decide if I feel confident enough in each case and so able to support that decision. The risks to be considered relate to blood pressure, whether or not you smoke, are overweight, have diabetes, have a family history of heart attack or stroke, have had angina or a TIA in the past. If you say yes to any one of these risk factors, it means that I would not be able to prescribe a triptan because the potential risk to you outweighs the potential benefit. So the final decision to issue a prescription for any medicine rests with the doctor issuing the prescription who has to feel confident that it is safe for you to take it and that the benefits outweigh any risks. Doctors of course have a responsibility to follow the guidance issued by the licensing authorities which is reflected in the information documented within the BNF, and to ensure that it is safe for you to take any medication prescribed. While this may be frustrating to you, rest assured that your doctor s prime concern is for your safety.

6 FAQs 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 migrainelike symptoms develop for people over 60 years, underlying health conditions may be responsible. You should talk to your healthcare professional if you have any concerns. Can my migraine symptoms change over time? Migraine symptoms can change throughout a person s lifetime. Migraine with aura is more common as migraineurs get older. Pain may not be as severe, symptoms may be less intense and attacks may reduce in frequency. It is possible to have attacks 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. You should discuss any changing symptoms with your healthcare professional if you are experiencing any. What if I have more than one health condition? Developing medical conditions increases with age and sometimes other health conditions have implications for migraine your treatment. Conditions, such as hardening of the arteries, high blood pressure, diabetes, heart disease or stroke, may have implications for the management of migraine. In addition, having another health condition can trigger more migraines but other migraineurs find treating their co-existing health condition reduces the amount of migraine attacks they experience. For further information about migraine and stroke, please visit Can migraine cause any long term damage? There is no firm evidence that having migraine causes permanent damage to your brain.

7 Hints and tips Medication Have an open discussion with your GP about the use of acute treatment for your migraines. If you feel you need triptan medication (Imigran, Zomig, Naramig, Maxalt, for example), voice your case. However, also listen to your doctor s advice if you are advised that the medicine is not appropriate. If acute treatments are not appropriate, discuss preventative medications available on prescription with your GP which may be more suitable. Continue to discuss options with your GP if you don t feel you have found the right medication for you and migraine is having a big negative impact on your quality of life. Food supplements Food supplements can be of great benefit to the more mature migraineur. For further information about supplements, please visit Popular choices include: Magnesium - has been shown in trials to be beneficial. The dosage required is 300mg - 600mg daily. Vitamin B2 - in doses of 400mg daily (well above the recommended RDA) has been shown to be helpful. Co-Enzyme Q10 - a compound made naturally in the body and used by cells to produced energy needed for cell growth and maintenance. The dosage required is 100mg three times daily. Fish oil supplements and cutting out all caffeine have been reported to help reduce aura. Lifestyle Try to avoid anything which you know triggers your migraine. Maintain a healthy lifestyle: eat regularly, drink at least two litres of water every day, endeavour to get some fresh air and light exercise each day, maintain regular sleep patterns, and restrict your intake of caffeine and alcohol. Practise relaxation techniques to rid the body of tension and stress. This could mean yoga, a massage, meditation, reflexology, a swim or a hot bath. For further information about relaxation and physical therapies, please visit or Put yourself first at least once a day - allow time for yourself for privacy, quiet and introspection. Don t take on too much, delegate and learn to say no. Don t give up trying to manage your migraine. Migraines do often change over time, as do triggers and responses to treatments and therapies. For further information about managing your migraine, please visit

8 Web: Headaches specific to later life 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 speak to your healthcare professional. The types of unusual headache include: Hypnic headache This is a rare type of headache which usually affects people over 50 years. 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 minutes. Temporal arteritis This condition usually affects women over the age of 50 years. 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 jaw muscles. If you suspect that you may have temporal arteritis it is really important that you seek medical advice. Steroids are usually effective in treating this headache type. 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. The condition is usually controlled effectively with a drug called carbamazepine. For further information, advice on migraine management and for updates on the latest migraine research, please contact Migraine Action by calling , ing or visiting the charity s website at All of our information resources and more are only made possible through donations and by people becoming members of Migraine Action. Visit to support one of our projects or visit to become a member. With thanks to: Migraine Action would like to thank Dr Manuela Fontebasso, a GP in York with a special interest in migraine for providing information used in this booklet. 4 th Floor, 27 East Street, Leicester. LE1 6NB. Tel: Fax: Web: Registered Charity No Copyright 2010 Migraine Action This publication provides information only. Migraine Action and its officers can accept no responsibility for any loss, howsoever caused, to any person acting or refraining from action as a result of any material in this publication or information given. Whilst this booklet has been reviewed for accuracy by members of Migraine Action s Medical Advisory Board and other experts, the information does not necessarily reflect the views of individuals. Medical advice should be obtained on any specific matter.

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