Self-regulatory treatment of headache in the elderly

Diagnosis and Treatment of Primary Headache Disorders in Older Adults

OBJECTIVES

To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature.

DESIGN

Review of the most current and relevant headache literature for practitioners specializing in geriatric care.

RESULTS

Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging.

CONCLUSION

The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults. J Am Geriatr Soc 66:2408-2416, 2018.

Psychological issues in the evaluation and treatment of tension-type headache

Tension-type headache is the most common headache disorder, affecting approximately 40 % of Americans within a one-year span. Although the most common form, episodic tension-type headache, is rarely impairing, more frequent tension-type headache can occur with significant disability and psychological comorbidity. Appreciating the psychological impact, assessing the associated biopsychosocial issues, and understanding patients' coping styles are important in forming an appropriate treatment plan and maximizing treatment outcomes. A range of psychological therapies including relaxation training, cognitive behavioral therapy, biofeedback and mindfulness have demonstrated utility in treating chronic pain conditions and reducing the associated disability. This may be particularly applicable to special populations, including pediatric patients, pregnant patients and geriatric. Psychological assessment and treatment may be done conjointly with medication management and expands treatment options. There is great need to continue researching the effects of psychological treatments, standardizing interventions and making them available to the wider population.

The effectiveness of cognitive and behavioural treatment of chronic pain in the elderly: a quantitative review

This study provides a meta-analytic review of cognitive and behavioural interventions for chronic pain in the elderly, focusing on treatment effectiveness. Included in the analysis are studies in which a comparison was made either to a control condition or to pre-treatment. A total of 12 outcome studies published or reported between January 1975 and March 2008, were identified involving participants 60 years and above and providing 16 separate treatment interventions. The analysis indicated that cognitive and behavioural interventions were effective on self-reported pain experience, yielding an overall effect size of 0.47. However, there were no significant effects of cognitive and behavioural treatment on symptoms of depression, physical functioning and medication use. Methodological issues concerning design, outcome measures and treatment are discussed and recommendations for future studies are outlined.

Mind–Body Interventions for Chronic Pain in Older Adults: A Structured Review: Table 1

STUDY DESIGN

We conducted a structured review of eight mind-body interventions for older adults with chronic nonmalignant pain.

OBJECTIVES

To evaluate the feasibility, safety, and evidence for pain reduction in older adults with chronic nonmalignant pain in the following mind-body therapies: biofeedback, progressive muscle relaxation, meditation, guided imagery, hypnosis, tai chi, qi gong, and yoga.

METHODS

Relevant studies in the MEDLINE, PsycINFO, AMED, and CINAHL databases were located. A manual search of references from retrieved articles was also conducted. Of 381 articles retrieved through search strategies, 20 trials that included older adults with chronic pain were reviewed.

RESULTS

Fourteen articles included participants aged 50 years and above, while only two of these focused specifically on persons aged >or=65 years. An additional six articles included persons aged >or=50 years. Fourteen articles were controlled trials. There is some support for the efficacy of progressive muscle relaxation plus guided imagery for osteoarthritis pain. There is limited support for meditation and tai chi for improving function or coping in older adults with low back pain or osteoarthritis. In an uncontrolled biofeedback trial that stratified by age group, both older and younger adults had significant reductions in pain following the intervention. Several studies included older adults, but did not analyze benefits by age. Tai chi, yoga, hypnosis, and progressive muscle relaxation were significantly associated with pain reduction in these studies.

CONCLUSION

The eight mind-body interventions reviewed are feasible in an older population. They are likely safe, but many of the therapies included modifications tailored for older adults. There is not yet sufficient evidence to conclude that these eight mind-body interventions reduce chronic nonmalignant pain in older adults. Further research should focus on larger, clinical trials of mind-body interventions to answer this question.

Practical considerations for the treatment of elderly patients with migraine

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.

Clinical psychology issues in migraine headaches

The important developments in our understanding and harnessing the biology of migraine have not diminished the need to consider the psychology of migraine. Psychological treatments especially relaxation training and biofeedback have been well validated as effective in treating frequent migraine. When the frequency and severity of migraine warrants more than analgesics, these treatments are the first line treatment for adults who cannot or do not wish to take abortive or prophylactic medications and for adolescents. The use of psychological interventions to enhance compliance to treatment or treatment effects is an underutilized resource. Psychological measurement is also critical in development and understanding of quality of life scales and the examination of decision-making by patients in taking medication. Modern clinical psychology has much to offer in the study of migraine and the amelioration of suffering from this common problem.

Psychophysiologic Therapy for Chronic Headache in Primary Care

BACKGROUND: Headaches account for a high percentage of office visits to primary care physicians, with migraine and tension-type headaches the most common. This article provides a summary of psychophysiologic therapies for migraine and tension-type headache and considers psychosocial factors relevant to headache. Psychophysiologic therapy of headache consists primarily of relaxation and biofeedback. METHOD: Representative controlled studies, meta-analysis, and reviews are utilized to assess the efficacy of biofeedback and relaxation for migraine and tension-type headache. RESULTS: Psychophysiologic therapy comprising biofeedback and relaxation can be provided in standard or limited therapist contact formulas to patients as sole therapy or concurrently with medical therapy. Effectiveness has been demonstrated for thermal biofeedback-and electromyograph biofeedback-assisted relaxation with minimal or no side effects. A typical treatment protocol is offered to exemplify the integration of psychophysiologic therapy into primary care practice. CONCLUSION: Psychophysiologic therapy represents an important adjunctive treatment for chronic benign headache that can be incorporated into primary care.

Biobehavioral pain research: a multi-institute assessment of cross-cutting issues and research needs

In 1994 ten NIH institutes sponsored an interagency workshop focusing on biobehavioral pain research. The workshop had three major goals: (1) to review the current status of biobehavioral pain research (2) to identify critical research needs, and (3) to enhance interdisciplinary and interagency cooperation in pain research. The purpose of this article is to summarize the presentations at this meeting and to highlight some of the key research recommendations. Research topics addressed include (a) understanding critical interfaces between biology and behavior; (b) pain, suffering, and emotion; (c) pain and behavior; (d) behavior-related interventions; (e) commonalities and differences in pain expression, experience, and treatment; and (f) pain in special populations. The article concludes with a summary of NIH pain research activities that have taken place since the workshop.

Behavioral management of migraine

Behavioral treatments for migraine have received increased attention over the past 25 years. In general, research has focussed on the six following areas: 1) comparative efficacy of treatments, 2) interplay of behavioral and pharmacological approaches, 3) development of delivery models that are cost-effective, 4) identification of characteristics associated with varied levels of response to treatment, 5) maintenance of effects and factors associated with long-term outcome, and 6) mechanisms of treatment. This paper briefly and selectively reviews the available literature in an attempt to point out the status of current research.

Psychological treatments for migraine

Psychological and behavioral treatments for migraine are described and evidence for their efficacy is reviewed. Treatments for children, adolescents, and the elderly, and for menstrual migraine are then discussed. Biofeedback, relaxation, and stress-coping treatments have all demonstrated effectiveness. These treatments are effective for the majority of migraine sufferers and treatment effects are reliably maintained for periods of at least one year. Little is known about the mechanism behind the efficacy of psychological treatments. Suggestions for future research on treatment mechanisms, enhancement of treatment effectiveness, and increasing the acceptance of psychological treatments are provided.

Headaches in the elderly

Headache prevalence and etiology vary dramatically with age. The prevalence of primary headache disorders, such as migraine and cluster, declines with age, while the prevalence of secondary headache disorders, such as temporal arteritis and mass lesions, increases. In evaluating elderly patients with new onset of headache, a high index of suspicion for organic disease is required. Headache symptomatology also varies with age. For example, migraine may evolve into a pattern of chronic daily headache, or auras may occur in the absence of headache (late-life migraine accompaniments). A careful longitudinal headache history is therefore important. Headache management is also influenced by age. Elderly people are more susceptible to medication side effects and are often treated with several drugs. Medications may cause headaches and drug interactions may complicate therapy. For these reasons, age of onset and duration of illness are critical headache features that guide the subsequent approach to diagnosis and treatment.

Biofeedback-assisted relaxation training for the aging chronic pain patient

The older segments of the U.S. population are expanding rapidly and account for a disproportionate amount of health care, including treatment for pain-related musculoskeletal disorders. In a prospective study with objective measures and one-year follow-up, Middaugh et al. (1988) found that older patients (55-78 yr; N = 17, 76% success) treated in a multidisciplinary chronic pain rehabilitation program enjoyed a success rate equal to that of younger patients (29-48 yr, N = 20, 70% success). The current study presents additional data on these two groups of patients to compare their ability to learn the physiological self-regulation skills taught in the biofeedback/relaxation component of the multimodal program. This component included progressive muscle relaxation training, diaphragmatic breathing instruction, and EMG biofeedback. Repeated measures ANOVA showed significant increases in digital skin temperature (peripheral vasodilation) and decreases in respiration rate both within and across training sessions (p values = .04 to .0001) with no differences between age groups (p greater than .05). EMG measures for the upper trapezius ms in patients with cervical pain showed similar deficits in muscle control at evaluation and similar improvements with biofeedback training for the two age groups. These findings indicate that older pain patients responded well to the biofeedback/relaxation training component of the multimodal pain program.

Electromyographic biofeedback training for tension headache in the elderly: a prospective study

This study evaluated the effects of a 12-session frontal electromyographic biofeedback training regimen on the headache activity of eight tension headache sufferers aged 62 and older. The biofeedback sessions were slightly modified for a geriatric population, essentially to increase comprehension and retention of rationale and instructions. Post-treatment assessment at three months revealed significant decreases in overall headache activity (50% or greater) in 50% of the subjects, and moderate improvement (35%-45%) in three of the remaining four subjects. Significant clinical and/or statistical pre-post differences were also found for the number of headache-free days, peak headache activity, and medication index. This is the first prospective study of biofeedback training for tension headache in an elderly population and, unlike previous retrospective studies, suggests that such therapy may be an effective intervention in the treatment of tension headaches in the elderly.