Management of Episodic Nausea, Headache, and Anorexia in a 77-Year-Old Patient
This presentation warrants immediate evaluation for migraine headache with associated nausea, but you must first rule out secondary causes—particularly temporal arteritis given the patient's age—before initiating migraine-specific therapy.
Initial Diagnostic Approach
Rule Out Secondary Causes First
In a 77-year-old with episodic headache and nausea, you must screen for dangerous secondary etiologies before assuming a primary headache disorder 1, 2:
Temporal arteritis (giant cell arteritis): This is critical in patients over 75 years old. Check ESR and CRP immediately; temporal arteritis was found in 0.6% of elderly headache patients in one series 3. Look for jaw claudication, scalp tenderness, visual symptoms, and temporal artery abnormalities on examination 1.
Medication overuse: Review all medications, including over-the-counter analgesics. Medication overuse headache occurs with ≥15 days/month of NSAID use or ≥10 days/month of triptan use 4.
Metabolic causes: Check for hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus, as these can cause both nausea and headache 4.
Basic workup: Obtain complete blood count, serum electrolytes, glucose, liver function tests, and lipase to exclude metabolic and gastrointestinal causes 4.
Consider Cyclic Vomiting Syndrome (CVS)
The episodic pattern ("every few days, comes and goes") raises the possibility of CVS, particularly if episodes are stereotypical 4:
- Mild CVS: <4 episodes/year, each lasting <2 days, without ED visits 4
- Moderate-severe CVS: ≥4 episodes/year, each lasting >2 days, requiring ED visits or hospitalizations 4
If CVS is suspected, one-time esophagogastroduodenoscopy or upper GI imaging can exclude obstructive lesions 4.
Treatment Strategy
If This Is Episodic Migraine with Nausea
Start with NSAIDs or acetaminophen at appropriate doses for acute episodes, and add a triptan if initial therapy fails 4.
For Acute Episodes:
First-line: NSAID (ibuprofen 400-800 mg, naproxen 500-1000 mg) or acetaminophen 650-1000 mg 4
If inadequate response: Add a triptan to the NSAID or acetaminophen. For severe nausea, use a nonoral triptan (sumatriptan 6 mg subcutaneous or 20 mg intranasal) 4.
Antiemetic therapy: Given the prominent nausea, add metoclopramide 10-20 mg every 6 hours or ondansetron 8 mg sublingual every 4-6 hours during episodes 4, 5. Metoclopramide has fair evidence as monotherapy for acute migraine attacks, particularly when nausea is present 4.
Alternative antiemetics: Prochlorperazine 5-10 mg every 6-8 hours or promethazine 12.5-25 mg every 4-6 hours 4. However, use caution with prochlorperazine in elderly patients due to risk of extrapyramidal symptoms and confusion 4.
Important Considerations for Age 77:
Avoid opioids and butalbital for migraine treatment 4
Diphenhydramine: Use with extreme caution in this age group due to anticholinergic effects, oversedation, and confusion 4
Counsel early treatment: Begin therapy as soon as symptoms start, using combination therapy (triptan with NSAID or acetaminophen) to improve efficacy 4
If Frequent Episodes Occur:
Consider preventive medications if episodes are frequent or treatment provides inadequate response 4.
If This Is Cyclic Vomiting Syndrome
For Mild CVS (<4 episodes/year):
Abortive therapy only 4:
Triptans: Sumatriptan 20 mg intranasal or 6 mg subcutaneous, single dose, may repeat once after 2 hours (maximum 2 doses in 24 hours) 4
Antiemetics: Ondansetron 8 mg sublingual every 4-6 hours 4
Sedatives: Lorazepam or alprazolam 0.5-2 mg every 4-6 hours during episodes 4. However, use with caution in elderly patients due to risk of CNS depression and paradoxical aggression 4.
For Moderate-Severe CVS (≥4 episodes/year):
Both prophylactic and abortive therapy 4:
Prophylactic therapy: Tricyclic antidepressants (amitriptyline starting 25 mg at bedtime, goal 75-150 mg) are first-line 4. However, in a 77-year-old, nortriptyline may be better tolerated due to fewer anticholinergic effects 4.
Abortive therapy: Same as mild CVS above 4
Lifestyle Modifications
Regardless of diagnosis, emphasize 4:
- Staying well hydrated
- Maintaining regular meals (addresses the anorexia)
- Securing sufficient and consistent sleep
- Engaging in regular physical activity
- Managing stress with relaxation techniques
- Identifying and avoiding triggers
Critical Pitfalls to Avoid
Do not assume primary headache without screening for temporal arteritis in this age group 1, 3
Do not use anticholinergic medications liberally (diphenhydramine, promethazine) in elderly patients due to confusion and oversedation risk 4
Monitor for medication overuse headache if analgesics are used frequently 4
Check baseline ECG before ondansetron due to QTc prolongation risk 4
Avoid triptans if the patient has ischemic heart disease, stroke, peripheral vascular disease, or uncontrolled hypertension 4