SCOTTSDALE, ARIZ. – Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at a symposium sponsored by the American Headache Society.
The possibility of secondary headache is greater in older patients, who often experience polypharmacy and drug interactions, said Dr. Swanson, professor and chair of the division of neurology at the Mayo Clinic Medical School in Rochester, Minn.
Headache ranks as the 10th most common symptom among elderly women and the 14th among elderly men.
Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).
Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease–both of which are more common in the elderly–as well as medication-induced headaches.
Giant cell arteritis, a necrotizing, granulomatous arteritis rarely seen before age 50, also should be considered. “New-onset headache is the key with giant cell arteritis,” Dr. Swanson said. Other common symptoms of giant cell arteritis include jaw claudication (which occurs in about 40% of cases), fatigue, and fever.
When elderly patients present with a headache, it is important to obtain a detailed history. It's especially important to get a detailed medication history. Why? “Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects,” Dr. Swanson said.
Elderly patients are also prone to have a reduced tolerance to those side effects, he pointed out.
Headaches that are associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.
The list of drugs that could be etiologic includes antibiotics, such as tetracycline; bronchodilators; cardiovascular drugs, such as vasodilators and antihypertensives; sedatives and stimulants; antidepressants, such as selective serotonin reuptake inhibitors; and reproductive drugs, such as estrogen.
With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists. Migraine headaches, for instance, peak in prevalence at about age 40 and are thus less common in the elderly.
That means migraines make up about 8% of headaches in women over age 60 and 3% in men. However, the literature indicates that migraines develop in about 2% of patients over age 50.
In the elderly, migraine headaches can present with reduced severity and frequency than in younger patients. But there can also be what neurologist C. Miller Fisher, M.D., described as “late-life migraine accompaniments”–including new onset of focal neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.
Tension-type headaches, though also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.
Treatment of migraine or tension-type headaches in older patients can be difficult. It is important to keep in mind that if a prophylactic approach is used with elderly patients, the starting dose should be low and with slow increases, Dr. Swanson said.
Cluster headaches, though also infrequent, are more common among men.
“Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography],” he said.
Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups, he said.
First described in 1988 and still rare, the hypnic headache is a dull one that develops only during sleep, yet with “clocklike regularity.” In addition, the hypnic headache is not attributed to any other disorder.
Treatments for the hypnic headache include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted.