History
A female patient in her 70s has a history of migraines without aura since childhood. She experienced an increase in the frequency of her usual migraines following administration of cervical epidural steroid injections in July 2018.
Presentation and examination
She reported that her migraines were characterized by holocephalic pain that would be greater on either the right or the left. This was associated with photosensitivity, nausea and vomiting. Her migraines were occurring two to three times per week, with milder headaches daily, and was taking sumatriptan for abortive management of the pain. This was not sufficient, and she was running out of her monthly supply.
Her migraine characteristics were the same as what she had always experienced, but with increased frequency. The triggers for her migraines were neck pain and weather changes.
She was not on a preventive migraine medication, but it is notable that she was on amlodipine and lisinopril for hypertension (HTN), and sertraline for depression.
Her neurologic examination was notable for mild end point tremor but was otherwise unremarkable. A CT of her brain was unremarkable, and a CT of her cervical spine showed mild degenerative changes of the cervical spine. She has a spinal cord stimulator for chronic pain, so an MRI could not be obtained. However, she had an MRI brain in 2017 prior to spinal cord stimulator placement that was normal.
I diagnosed her with chronic migraine without aura, intractable after cervical epidural steroid injections that were not effective in treating her neck pain. Her tremor on examination resolved after discontinuation of sertraline.
Treatment
We initially tried topiramate, which caused a mild rash, and it was determined that she had a sulfa allergy. She also did not find it to be helpful for her headaches. We also tried a nutraceutical — magnesium oxide — which was slightly helpful.
Compazine given for nausea with her migraines was not covered by her insurance, so metoclopramide was utilized. Beta blockers and calcium channel blockers that could be used for preventive management of migraines were not options for her because she was already on two agents for treatment of HTN. The tricyclic antidepressant class of medications was not an option due to her age, risk of falls (she has severe osteoporosis) and risk of QT prolongation. Gabapentin did not help her migraines.
Due to minimal oral options for management of her migraines in the setting of intolerability, inefficacy and risk of medication interactions, we moved forward with botulinum toxin (Botox) injections.
Outcome
After six months (two cycles, three months apart) of Botox injections, she went from having chronic daily headaches with superimposed two to three migraines per week, to no migraines and only occasional neck pain-related headaches. A year later, she would still get occasional migraines, which would resolve with Rimegepant taken at onset of migraine.
Discussion
In this case, we have a patient who had migraines since she was a young woman but had worsening symptoms in her 70s. In addition to ruling out insidious causes of headache in the elderly, an appropriate treatment regimen also needs to be identified.
Migraine management can be challenging when patients are elderly due to the risks of medication interactions, intolerance or inefficacy. Other comorbidities also must be taken into consideration when selecting an appropriate medication. By utilizing treatment options that do not act in a systemic manner and do not interact with other medications, we were able to identify a regimen for migraine management that was safe and effective for this patient.
