Primary Headaches in an Elderly Population Seeking Medical Care for Cognitive Decline

The Ketogenic Diet in the Prevention of Migraines in the Elderly

Migraines display atypical age dependence, as the peak of their prevalence occurs between the ages of 20-40 years. With age, headache attacks occur less frequently and are characterized by a lower amplitude. However, both diagnosis and therapy of migraines in the elderly are challenging due to multiple comorbidities and polypharmacy. Dietary components and eating habits are migraine triggers; therefore, nutrition is a main target in migraine prevention. Several kinds of diets were proposed to prevent migraines, but none are commonly accepted due to inconsistent results obtained in different studies. The ketogenic diet is featured by very low-carbohydrate and high-fat contents. It may replace glucose with ketone bodies as the primary source of energy production. The ketogenic diet and the actions of ketone bodies are considered beneficial in several aspects of health, including migraine prevention, but studies on the ketogenic diet in migraines are not standardized and poorly evidenced. Apart from papers claiming beneficial effects of the ketogenic diet in migraines, several studies have reported that increased levels of ketone bodies may be associated with all-cause and incident heart failure mortality in older adults and are supported by research on mice showing that the ketogenic diets and diet supplementation with a human ketone body precursor may cause life span shortening. Therefore, despite reports showing a beneficial effect of the ketogenic diet in migraines, such a diet requires further studies, including clinical trials, to verify whether it should be recommended in older adults with migraines.

Episodic Migraine and Older Adults

PURPOSE OF REVIEW

Migraine is and continues to be a significant medical issue in older adults. Migraine can have different characteristics in older adults and specific diagnostic and treatment considerations need to be applied when managing headache and migraine in this population, which is increasing in both size and diversity. Contrary to widely held beliefs, migraine may not improve in older women following menopause and can have new onset in older age. The purpose of this review is to give an update on the diagnosis and treatment of episodic migraine in older adults.

RECENT FINDINGS

As the population ages, migraine in older adults will become a more significant public health issue. Migraine in older adults can present with different clinical symptoms than in a younger population and is primarily a diagnosis of exclusion in older adults. Migraine treatment considerations for older adults should include comorbidities and medication interactions. Recent findings suggest there are medications that should be avoided when treating seniors with migraine. The purpose of this review is to give an update on the most important aspects regarding the diagnosis and treatment of headache and migraine in older adults. In addition, recommendations will be made concerning medications that need careful consideration when prescribing to seniors.

Is there a link between headache and cognitive disorders? A systematic review

BACKGROUND

The overall prevalence of headaches decreases with age; however headaches remain frequent in aged individuals who are also affected by other disorders such as cognitive decline. Despite the high frequency of both conditions in these persons, the association between headaches and cognitive decline is underexplored, underdiagnosed and poorly understood.

OBJECTIVE

In the present article, we aim to provide a comprehensive review of existing data concerning the link between headache and cognitive decline.

METHODS

We undertook a systematic literature review to report articles that focus on headaches (including all types of headaches) and neurocognitive disorders of degenerative causes.

RESULTS

Only 9 studies have explored the association between headaches and neurocognitive decline. Methods were highly variable from population-based study to short series of patients using either database or questionnaire during consultation. Studies focusing on Familial Alzheimer's Disease revealed a very high prevalence of headaches in mutation carrier patients compared to non-carrier patients.

CONCLUSION

The association between headaches and cognitive decline is underexplored. Future studies are needed to address the pathophysiological mechanisms to improve the treatment of these underestimated headaches.

Headache - A Window to Dementia: An Unexpected Twist

Migraine and other types of headaches have several symptoms associated with them. The association between migraine and dementia has been considered. It is a topic of discussion and appears to be multifactorial. Dementia is a cluster of symptoms, with memory loss and cognitive dysfunction being the prominent symptoms. In this review, we discussed the association of headache and cognitive dysfunction in a broader context and how the practiced treatment of headaches may silently lead to dementia. We conducted a thorough literature search using PubMed as our main database. The articles exploring the association between headache (both migraine and non-migraine) and dementia were included. Some risk factors like migraine-induced stroke and inherent vascular diseases in migraine patients channeling to stroke and dementia were not considered. A total of 28 studies were included for review. All the reviewed studies put together showed an association between headache and cognitive dysfunction of any form. They showed that the frequency and duration of headache is a determinant for dementia. Few studies also focused on how treating headaches with certain drugs can lead to dementia. The reviewed published literature showed that headaches of any sort and their treatment are potentially linked to dementia. Not all headache patients will require medical treatment, as the benefit might outweigh the risk sometimes. It is interim to understand these facts and formulate a better protocol for treating headache patients. However, due to some discordant results, further studies are needed.

Casticin ameliorates scopolamine-induced cognitive dysfunction in mice

ETHNOPHARMACOLOGICAL RELEVANCE

The fruit of Vitex rotundifolia L. (Verbenaceae) has been used in traditional medicine as sedative or analgesic agent for headache. Recent population-based cohort studies have shown that headache including migraines is a risk factor for dementia. Thus, the fruit of V. rotundifolia may be useful for treating cognitive dysfunction observed in dementia.

AIM OF THE STUDY

We had previously found that the ethanolic extract of the fruit of V. rotundifolia ameliorated cognitive dysfunction and isolated casticin as an active compound. In the present study, we studied the effect of casticin on a mouse model of cognitive impairment induced by scopolamine.

MATERIALS AND METHODS

Mice were treated with the ethanolic extract of the fruit of V. rotundifolia (EEVR; 30, 100 or 300 mg/kg, p.o.) or casticin (0.3, 1 or 3 mg/kg, p.o.). We examined the effect of casticin or EEVR using the passive avoidance test, the Morris water maze test and the novel object recognition test. Scopolamine (1 mg/kg, i.p.) was used to induce cognitive impairment by blocking cholinergic neurotransmitter system. We investigated the effects of casticin on acetylcholinesterase (AchE) activity and the phosphorylation levels of extracellular signal-regulated kinase (ERK), cAMP response element binding protein (CREB), and the expression levels of brain-derived neurotrophic factor (BDNF).

RESULTS

EEVR (100 and 300 mg/kg, p.o.) significantly ameliorated the latency in the passive avoidance test, and casticin (1 and 3 mg/kg, p.o.) also significantly improved the latency in the passive avoidance test, novel object preference in the novel object recognition test, and swimming time in the target quadrant of the Morris water maze test. Casticin also decreased AChE activity in ex vivo analysis and increased the phosphorylation levels of memory-related signaling molecules, such as ERK, CREB and BDNF in the cortex.

CONCLUSION

These results suggest that casticin ameliorates cholinergic blockade-induced cognitive impairment, in part, through the inhibition of AChE and the activation of the ERK-CREB-BDNF signaling pathway. Taken together, the results suggest that casticin may be useful for treating the cognitive dysfunction observed during cholinergic impairment.

Associations of Elderly Onset Headache With Occurrence of Poor Functional Outcome, Cardiovascular Disease, and Cognitive Dysfunction During Long-term Follow-up

Background

Although the frequency and intensity of headaches decrease in older adults, headaches in this population are still an important neurological disorder. The purpose of this study was to investigate the associations of headache characteristics in older adults with the development of cardiovascular disease and cognitive dysfunction.

Methods

We prospectively enrolled 125 older (≥65 years old) patients with headache who were making their first visit to outpatient clinics and who had no prior history of cognitive dysfunction from 11 hospitals in Korea between August 2014 and February 2015. We investigated the occurrence of newly developed/or recurrent headache, cardiovascular disease, cognitive dysfunction, and poor functional outcomes.

Results

The mean age of all included patients was 72.6 years, 68.8% were women, and 43 (34.4%) had newly developed/or recurrent headache during follow-up. During a median follow-up of 31 months (interquartile range, 28–34 months), 21 participants (16.8%) experienced cardiovascular disease, and 26 (20.8%) developed cognitive dysfunction. Upon multivariate analysis and after adjusting for sex, age, and other factors, presence of newly developed/or recurrent headache was found to be associated with cardiovascular disease (hazard ratio [HR], 4.03; 95% confidence interval [CI], 1.28–12.61; p=0.017) and frequency of headache for the recent 3 months was related with cognitive dysfunction (HR, 1.05; 95% CI, 1.00–1.09; p=0.017) and poor functional outcomes (HR, 1.06; 95% CI, 1.01–1.11; p=0.011).

Conclusion

Our study demonstrated that there is an increased risk of cardiovascular disease, cognitive dysfunction, and poor functional outcomes in older patients with frequent, newly developed, or recurrent headache.

Circadian rhythms of migraine attacks in episodic and chronic patients: a cross sectional study in a headache center population

Background

Migraine is considered a disease with diurnal and 24 h pattern, though the existence of a prevalent circadian rhythm associated to migraine frequency and severity is still not clear. This observational cross-sectional study aimed to:

1. Assess the circadian rhythm of migraine attacks onset in a large patients’ population selected in a headache center and including episodic and chronic migraine 2. Analyze the principal characteristic of the different onset time groups 3. Verify if migraine features, particularly those associated to chronic and disabling migraine, could be discriminant factors for time of onset group.

Methods

We selected 786 consecutive migraine outpatients, who correctly completed the headache diaries for 3 consecutive months and who fulfilled the diagnosis of migraine without aura-MO, migraine with typical aura alone or associated to migraine without aura - MO/MA and chronic migraine – CM. For the time of headache onset, we considered four time slots, from 6 to 12 am (morning), from 1 to 6 pm (afternoon), from 7 to 11 pm (evening), from 12 pm to 5 am (night), and an additional category named “any time”. Each time slot included the 60 min preceding the next one (e.g. an onset at 12.30 am was included in 6–12 am time slot). We evaluated in all patients the pericranial tenderness, anxiety and depression tracts, headache-related disability, sleep features, quality of life, allodynia and fatigue.

Results

We scored a total of 16,578 attacks, distributed in the entire day. The most of patients, including CM, satisfied the criteria for the “any time” onset. Night onset was significantly less represented in the MA/MO group. Patients with prevalent night onset were significantly older, with longer migraine history and shorter sleep duration. Age and illness duration were the variables discriminating the different onset time groups.

Conclusions

The most of migraine patients do not report a specific circadian profile of attacks occurrence. Frequent migraine, severe disability, psychopathological tracts as well as central sensitization signs, do not match with a specific circadian rhythm of attacks onset. Night onset migraine seems to be an age related feature, emerging in the course of the disease.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1098-0) contains supplementary material, which is available to authorized users.

Age-Related Changes in Headache Days across the Cognitive Spectrum

Introduction

Prior studies demonstrating age-related declines in headache prevalence have not accounted for the potentially confounding effects of cognitive impairment. Our primary goal was to assess the relationship between aging and self-reported monthly headache days across the cognitive spectrum.

Methods

A detailed headache questionnaire was included prospectively as part of an annual mailing to participants in the Sanders-Brown Center on Aging longitudinal cohort.

Results

The overall survey response rate was 58.6%, yielding a cohort of 332 cognitively normal, 71 mild cognitive impairment (median Mini-Mental Status Examination [MMSE] score = 27, interquartile range [IQR] = 25-28), and 51 demented (median MMSE score = 24, IQR = 19-26) individuals. Current headaches were reported by 22.8%, 25%, and 27.1%, respectively, across normal, mild cognitive impairment, and dementia subgroups. A negative correlation was observed between age and average headache days in cognitively normal (ρ = -0.163, 95% confidence interval [CI] = -0.246 to -0.022, P = 0.004), mild cognitive impairment (ρ = -0.255, 95% CI = -0.274 to 0.229, P = 0.0475), and dementia groups (ρ = -0.295, 95% CI = -0.457 to 0.159, P = 0.068). Ordinary least-squares regression with backward selection identified age alone, but not gender or MMSE, as predicting headache days in the overall cohort.

Conclusions

Aging is associated with a decline in headache days in the absence of any confounding cognitive pathology and is weakly predictive of headache days across the cognitive spectrum. Whether this represents a reporting bias due to dementia or has neurobiological significance warrants further investigation.