MSGM Clinical Case Discussion May 2026

Headache in Parkinson Disease – An Out-of-the-Box Approach

Prepared by: Dr Loganayagee Subramaniam

Supervisor: Dr Goh Cheng Beh, Dr Tan Hui Loo

Madam A, an 84-year-old Chinese lady with multiple comorbidities was admitted on 21/2/2026 with generalized body weakness, loss of appetite, and shortness of breath for one week.

Comorbidities:

1. Hypertension

2. Parkinson’s disease

3. Major neurocognitive disorder (mixed AD + VAD / Parkinson disease dementia with BPSD)

4. Osteoporosis with fragility fracture of left subtrochanteric fracture, post PFN in 2024

Medications:

● T. Madopar 187.5 mg QID

● T. Selegiline 5 mg OM

● T. Pramipexole 0.375 mg OD

● T. Memantine 10 mg OD

● S/C Denosumab 60 mg 6-monthly

● T. Clopidogrel 75 mg OD

● T. Amlodipine 10 mg OD

● T. Calcium carbonate 500 mg BD

● T. Mecobalamin 500 mcg BD

Premorbid Condition:

CSF: 6

Modified Barthel Index: 46

Mobility: mostly in wheelchair bounded

Cognition: MMSE trend (22-20-17-14)

Hoehn and Yahr stage: 4

UPDRS: 30/33/54/14(133/199)

During her current admission, she was diagnosed with E. coli bacteraemia secondary to urosepsis and treated with antibiotics. Upon examination, the patient was frequently noted to hold her head and complain of headache.

Further history revealed a two-year history of chronic headache occurring 3–4 times daily, which had progressively affected her sleep and overall quality of life, resulting in multiple doctor visits. Madam A was brought to Subang Jaya Medical Centre in October 2025 for a geriatrician review and was started on a rivastigmine patch 4.6 mg daily. The family also sought care from a private GP in January 2026 due to poor sleep related to headache, and she was prescribed with lorazepam 0.5 mg PRN. She was also seen at Hospital Mawar, where a CT brain performed three months prior showed multifocal lacunar infarcts.

During her inpatient stay, close observation and monitoring of symptoms identified a consistent temporal relationship between her headaches and her Parkinson’s medication schedule. The headaches were noted to occur just prior to the next scheduled dose of levodopa (Madopar) and would resolve within approximately one hour after medication intake. In addition, the patient complained of vertigo symptoms and was given T. betahistine. She also had urinary incontinence and vaginal discharge, which were disturbing her sleep.

In view of this, a multidisciplinary discussion was held with the neurology team, and a decision was made to rationalise her medications by withholding selegiline and pramipexole, while continuing levodopa (Madopar) as the mainstay of therapy, along with memantine and as-needed quetiapine for behavioural symptoms. Madam A was also referred to ophthalmology and orhinolaryngology teams to exclude other secondary causes of chronic headache. Ophthalmology assessment was limited due to poor patient cooperation, while ENT review noted chronic otitis media. She was also reviewed by the gynaecology team and treated with a vaginal pessary.

Over the course of two weeks of inpatient care, Madam A demonstrated gradual clinical improvement. Her headache frequency reduced significantly, her sleep improved, and she became more engaged with rehabilitation. From an infectious standpoint, she completed a full two-week course of antibiotics for E. coli bacteraemia. Further investigations, including ultrasound abdomen, showed no intra-abdominal collection, and echocardiography demonstrated no evidence of infective endocarditis.

Madam A was discharged well on 13/3/2026 with a simplified medication regimen. Patient was discharge with T.madopar 187. , T.memantine , T.clopidogrel, T.quetiapine ,T. caco3, T.mecobalamin and S/c Denusumab. Follow-up appointments were arranged with the geriatric clinic, as well as ENT, ophthalmology, and gynaecology teams.

Comprehensive education was provided to her family regarding the risks of polypharmacy, the importance of medication adherence and regular follow-up, and the potential harms associated with fragmented healthcare utilisation. This case highlights the importance of careful clinical observation, recognition of medication-related symptom patterns, and the role of multidisciplinary geriatric care in optimising outcomes for frail older adults with complex medical conditions.

Investigation

USG Abdomen: No evidence of intra -abdominal collection

ECG: Sinus Rhythm

Ct brain (December 2025): Multifocal chronic infarct

Discussion

1. How can the wearing-off phenomenon in Parkinson’s disease present as non-

motor symptoms in frail older adults, and why is it often missed?

2. What are the risks of polypharmacy, particularly dopaminergic therapy, in older

adults with Parkinson’s disease, and how can rationalisation improve outcomes?

3. How should a multidisciplinary geriatric approach (neurology, ENT,

ophthalmology, gynaecology, rehabilitation) be prioritised in managing

unexplained chronic symptoms in complex older patients?

4. How should structured family education be integrated in the management of

frail older adult with Parkinson’s disease with chronic multifactorial headache;

particularly to improve medication adherence, reduce polypharmacy risks, and

prevent fragmented healthcare-seeking behaviour?