HEADACHE IN THE ELDERLY - jhasim.com

1 S556 Vol. 3 (6C) June 2003 ABSTRACTH eadaches occur more frequently in theelderly than is commonly appreciated. This articlediscusses the challenges associated with diagnos-ing and managing HEADACHE disorders in theelderly and reviews the most common primaryheadache disorders (late-life migrainous accom-paniments, tension-type HEADACHE , clusterheadache, and hypnic HEADACHE ) as well as sec-ondary HEADACHE disorders (medication overuseheadache, giant cell arteritis, exploding headsyndrome, and lesional headaches). With a focuson the different presentations and etiologies ofheadache in patients older than 65 years, neu-rologists have many tools at their disposal forappropriate management. (Adv Stud ;3(6C):S556-S561) HEADACHE , migraine in particular, is typi-cally considered a disorder of youngerto middle-aged adults. The prevalenceof migraine is highest between the agesof 20 and 55 years, peaking at aboutage 40 years and declining ,2 However, theprimary HEADACHE disorders exist in older studies report that 53% of men and 64% ofwomen aged 55 to 74 years experience HEADACHE , as wellas 22% of men and 55% of women 75 years and is reported to be the 10th most commonsymptom in ELDERLY women and 14th most common inelderly demographic landscape of headacheetiology changes over time, from predominantly primaryheadaches in younger individuals to a greater incidence ofsecondary headaches in older individuals, regardless ofsex.

2 Yet, HEADACHE remains a significant health problemfor the geriatric population. Consider also that the elder-ly (ie, those aged 65 years and older) are the fastest grow-ing segment of the US ANDMANAGEMENTCHALLENGESO btaining an accurate and detailed history is essen-tial for any HEADACHE patient, but even more so withthe ELDERLY patient. A meticulous medication history isvital, because the potential clue to the HEADACHE sourcemay lie in the medication(s) the patient is taking. The primary HEADACHE disorders, including migraine,may either attenuate over time (reduced frequency, sever-ity and/or duration) or present in an atypical patients no longer experience the positive visualdisplay but may continue to experience the ensuingheadache. Chronic daily HEADACHE may continue intoolder age. In addition, 5% to 10% of patients older than65 years first develop chronic daily HEADACHE ; however,in the authors experience, many of these patients have ahistory of migraine.

3 Treatment of ELDERLY patients with headaches is farmore challenging than in their younger counterpartsfor several reasons, including the increased frequencyof secondary HEADACHE , comorbid or coexisting condi-tions, and polypharmacy. A single diagnosis may noPROCEEDINGSHEADACHE IN THE ELDERLY * David J. Capobianco, MD *Based on a presentation given by Dr Capobianco at theAmerican HEADACHE Society Scottsdale HeadacheSymposium. Assistant Professor, Mayo Medical School, Mayo Clinic,Jacksonville, correspondence to: David J. Capobianco, MD,Department of Neurology, Mayo Clinic, 4500 San Pablo Road,Jacksonville, FL 32224. E-mail: Studies inMedicine S557 PROCEEDINGS longer link the signs and symptoms into a neat, uni-fied HEADACHE classification; thus, excluding sec-ondary or symptomatic causes of HEADACHE isabsolutely essential. Coexisting diseases complicatetreatment, both acute and preventive.

4 Also, elderlypatients have reduced tolerance to medications dueto changes in hepatic and renal is common; 12% of the population isolder than 65 years, yet they consume more than onethird of all prescription ,6It is helpful,therefore, to obtain assistance from the patient s pri-mary care physician and/or the pharmacist for acomplete medication history. The advice to startlow and go slow is especially true for the is a summary of the major primary andsecondary HEADACHE disorders in the ELDERLY . TheFigure provides an algorithm for differential ANDLATE-LIFEMIGRAINOUSACCOMPANIMENTSA lthough the incidence of migraine peaks inmidlife, approximately one third of migraine patientscontinue to experience migraine headaches into olderage. The character of migraine attacks remains thesame: unilateral or bilateral temporal throbbing fre-quently associated with photophobia, phonophobia,or nausea, occurring more frequently in women.

5 Asmall percentage (2% to 3%) experience their firstmigraine after age 50 attacks can occur with aura, yet without theensuing HEADACHE . Late-life migrainous accompani-ments, described in Table 1, are an important considera-tion for the ELDERLY HEADACHE patient. The key feature isthe positive visual display, often beginning in one part ofthe visual field, then slowly spreading to involve 1 orFigure. HEADACHE in the ELDERLY An Algorithm for Differential DiagnosisAdapted with permission from Dodick DW, Capobianco DJ. Headaches. In: Sirven JI, Malamut BL, eds. Clinical Neurology of the Older Adult. Philadelphia, Pa: LippincottWilliams 2002. S558 Vol. 3 (6C) June 2003 PROCEEDINGS both eyes, and generally lasting 10 to 15 ,9As the positive visual display abates, the patient maythen experience positive sensory symptoms includ-ing tingling or prickling that may begin in the fin-gertips and spread to the palm or forearm, thenmove to the ipsilateral face and tongue, lasting sev-eral minutes.

6 As the sensory symptoms resolve inthe affected extremity, the patient may then experi-ence heaviness or clumsiness that lasts several min-utes. As the clumsiness abates, difficulty in wordfinding may ,9 Late-life migrainous accompaniments are oftenstereotypic attacks of short duration, lasting 20 to 30minutes. The attacks may be identical, suggesting thatthe mechanism is not cardioembolic. Patients havenormal neurological exams between one half of the patients may experiencea mild, nonspecific ,9 The key to differentiating late-life migrainousaccompaniments from vascular disease (eg, a transientischemic attack) is the serial progression between onesymptom or accompaniment to another. For example,an acute left middle cerebral artery ischemic infarctwould produce abrupt onset of right hemibody weak-ness (a negative symptom), right-sided numbness (anegative symptom), and visual loss (a negative symp-tom) all occurring migrainous accompaniments representa diagnosis of exclusion.

7 Therefore, appropriateneuroimaging and neurovascular studies, bloodwork, and, where appropriate, cardiac studiesshould be pursued. Treatment of late-life migrain-ous accompaniments consists typically of a calci-um channel blocker (eg, verapamil). Manyphysicians may also add an antiplatelet medications may also be a viableoption for some HEADACHE is more common in elder-ly than in younger populations, with a reportedprevalence of 27% in patients older than 65 yearscompared with 20% in the entire , it is difficult to ascertain the true epidemi-ology of tension-type HEADACHE in older personsbecause it can be confused with various disorders. Tension-type HEADACHE can be considered a fea-tureless HEADACHE dull, bilateral, or diffuseheadache of mild to moderate intensity. There is arelative paucity of accompanying migraine features (ie,nausea, photophobia, phonophobia, worsening withmovement).

8 Tension-type HEADACHE can easily be con-fused with structural or metabolic intracranial diseaseor depression, which are both more common in theelderly population, so careful examination for otherpotential causes is imperative. Tension-type HEADACHE , like migraine, in theelderly should be treated with nonpharmacologictherapies, with judicious use of abortive and preven-tive antimigraine medications. Approximately 10%of individuals will develop tension-type headacheafter age 50 years; in these patients, an organic causemust first be ruled headaches, due to the excruciating painthey inflict, are unmistakable. Sometimes referred to as suicide headaches, cluster headaches are character-ized by intense, severe pain in the orbital region, peak-ing about 5 minutes after onset, and lasting anywherefrom 15 minutes to 2 hours. Robust autonomic symp-toms (eg, lacrimation, nasal congestion, ptosis, meio-sis, rhinorrhea, or conjunctival injection) occur in thevast majority (97%) of HEADACHE is uncommon in the ELDERLY buthas been reported in patients as old as 80 years,accounting for 4% of ELDERLY patients presenting to aTable Criteria for Late-Life MigrainousAccompaniments Positive visual displays (eg, scintillating scotoma, fortification spectrum) Slow or gradual buildup of either visual or sensory symptoms Serial progression from one migrainous accompaniment visual tosensory to motor with a delay from one symptom or accompani-ment to another Occurrence of identical attacks Duration of 20 to 30 minutes Flurry of attacks in midlife (age 50 to 60 years) is common Complete resolution between attacks.

9 A benign course without sequelae Headaches do not follow accompaniments in nearly 50% of cases Exclusion of symptomatic etiologiesData from ,9headache HEADACHE features in theelderly are stereotypic, but diagnosis warrants imagingstudies to eliminate other possible causes, particularlywith any unusual features at presentation. Treatment is usually with nasal oxygen, barring anycoexisting medical contraindication. Nasal oxygen isthe safest treatment for those with comorbid cardio-vascular disease. Subcutaneous sumatriptan, althoughtypically very effective, should be avoided, especially inthose with cardiovascular risk factors a common sub-population of cluster HEADACHE patients. Prophylacticdrug therapy is the same as for younger populations,excluding methysergide. HYPNICHEADACHEH ypnic HEADACHE appears to be a primaryheadache disorder distinctly of the geriatric popula-tion, with a mean age of onset of approximately 60years.

10 This rare type of HEADACHE , also known as alarm clock HEADACHE , has an estimated prevalenceat the Mayo Clinic of only key featureof hypnic HEADACHE is its nocturnal onset (Table 2).Hypnic headaches typically begin between 1:00 AMand 3:00 AM, occurring more than 4 times per weekin two thirds of patients. Hypnic headaches are ofshort duration (<2 hours in 64% of cases) with alack of associated migrainous and autonomic symp-toms that would suggest an alternative primaryheadache disorder, such as cluster HEADACHE . Theheadaches are typically holocephalic and are of mod-erate severity. Approximately 58% of patientscomplain of a dull, nonpulsatile HEADACHE , but42% have some throbbing quality to the initially thought to be more common inmen, as the full spectrum of the hypnic headachesyndrome has evolved, it is apparent that womenare more commonly , resting in a supine position tendsto exacerbate the pain, so many patients may paceto relieve the pain.