Headaches in the Elderly

John G. Edmeads

Shuu-Jiun Wang

“Old age,” said the poet Bion (300 BC), “is the harbour of all ills.” A merciful exception is headache, which visits the elderly less. The 19^th-century poet Ralph Waldo Emerson wrote that “at fifty years … afflicted citizens lose their sick headaches,” and an eminent clinician, Moritz Romberg (31), stated in the first textbook of neurology (1853) that “hemicrania generally diminishes in advanced age.” Modern epidemiologists agree.

In Waters series (48), whereas 92% of women and 74% of men between the ages of 21 and 34 years had had a headache in the preceding year, the prevalence decreased to 66% and 53%, respectively, in the 55-to 74-year age group, and to 55% and 22% in the over-75-years age group.

CAUSES OF HEADACHE IN THE ELDERLY

As in the younger age groups, primary headache disorders such as migraine, tension-type headache, cluster headache, and chronic daily headache still account for most of the headaches that afflict the elderly (6,40,45,46). An important difference between the two age groups is that headaches due to other disorders (secondary or symptomatic headaches) are much more common in the aged than in the young, constituting a significant minority (10 to 20%) of cases in the elderly, especially for new-onset headache (22,24). In a recent survey of elderly patients in a headache clinic, onset after age 65 occurred in only 4.8% of those with primary headache disorders, whereas onset after age 65 occurred in 66.7% of patients with secondary headache disorders (24). Table 135-1 lists some of the toxic, metabolic, and structural diseases that may present with headache; all are distinctly more common in older people. One conclusion to be drawn from this is that the clinical approach to headache, always requiring care, requires more attention in the older patient, with correspondingly readier recourse to laboratory investigation and neuroimaging. This cautious approach is derived from clinic-based studies of patients. To put things into perspective, however, it should be noted that in a recent community-based study (31), secondary headache occurred in only 2.2% of elderly people with headaches.

Although older people are more likely than younger to suffer the various cranial neuralgias, these syndromes seldom are described as “headache” and thus are not discussed here (see Chapters 126 and 127).

PRIMARY HEADACHE DISORDERS IN THE ELDERLY

Migraine

Though migraine attenuates with age, a significant number of the elderly remain troubled by it. Indeed, some (1 to 3%) experience migraine for the first time in their lives after the age of 50 (30,36). The prevalence of International Headache Society (IHS) migraine in the elderly has been variously estimated at between 3% and 11% (29,31,37,46), with more women than men affected and the prevalence declining with advancing age. It is noteworthy that the female:male ratio is around 3:1 in the young and middle-aged population but declines to 2:1 after the age of menopause (23).

The changes in the profile of migraine through the ages have not been fully described (26). Migraine with aura is relatively less prevalent in the aged than in the young in all series, reflecting the well-known clinical observation that people tend to lose their auras as they get older. The converse may occur; that is, patients who have had migraine with aura when younger may lose their headaches as they age and have only recurrent painless auras (49). In a series of headache-clinic outpatients over the age of 60 years, 12% had migraine with aura, and 55% of these had at least some of their visual auras without an after-coming headache (26). These episodic focal disturbances may be confused with transient ischemic attacks (TIAs),
particularly if the prior history of migraine has not been elicited. Fisher described these episodes as late-life migraine accompaniments (12) and provided guidelines that may help to distinguish these essentially harmless transient episodes from the more ominous TIAs. Recently, it was reported in a subgroup of patients with presumed TIA that there is a benign short-term course if the attacks are multiple, brief (duration of spell ≤10 minutes), and characterized by sensory symptoms (19); these may be not TIAs, but migraine accompaniments.

TABLE 135-1 Causes of Headache in the Elderly

*Primary headache disorders*
Migraine
Tension-type headache
Cluster headache
Chronic daily headache
Hypnic headache
SUNCT syndrome
*Secondary headaches*
Toxic and metabolic headaches
	Medications (including medication-overuse headache)
	Chronic respiratory disease
	Hypercalcemia
	Hyponatremia
	Chronic renal failure
	Anemia, polycythemia
Structural lesions
	Cervical spondylosis and disc disease (vs. cervicogenic headache)
	Giant cell arteritis
	Atherothrombotic cerebrovascular disease
	Severe hypertension
	Intracranial mass lesions, including hydrocephalus and hematomas
	Meningeal irritation: hemorrhage and infection
SUNCT, short-lasting, unilateral, neuralgiform headache with conjunctival injection and tearing.

Various conditions that occur in old age, or sometimes the medications taken for these conditions, may aggravate migraine or make it more resistant to treatment. For example, high blood pressure may make coexistent migraine difficult to treat (44). Some of the drugs used to treat hypertension are useful as migraine prophylactics (e.g., beta-blockers, calcium channel blockers, and angiotensin-II-receptor blocker [43]), but others (e.g., methyldopa) may make migraine worse. Ischemic heart disease, common in the elderly, does not in itself worsen migraine, although very rarely it may present primarily as migrainelike headache (21), which is usually accompanied by less conspicuous chest or left arm discomfort. The second edition of the International Classification of Headache Disorders (ICHD-II) (18) calls this “cardiac cephalalgia.” These cardiac headaches tend to clear with nitrates, whereas in the much more typical situation, a patient with anginal chest pain who takes nitrates will precipitate a headache that, in the case of a migraine sufferer, may be overtly migrainous.

Treatment of migraine thus presents special problems in the elderly. Coincidental disease may prohibit the use of some migraine medications. For example, vascular disease in general contraindicates the use of ergotamine, dihydroergotamine, and the triptans; depression militates against the use of beta-blockers and flunarizine; the beta-blockers and calcium channel blockers should not be used in heart failure; and prostatism, glaucoma, and heart disease make the use of tricyclics problematic. Moreover, even when these contraindications do not exist, older patients are more likely than younger patients to develop adverse effects from migraine medications. For example, the elderly are especially prone to have sedation and confusion from tricyclics, and their decreased renal reserve makes them vulnerable to kidney failure with nonsteroidal antiinflammatory drugs (NSAIDs).

Managing the older migraine patient calls for thorough familiarity with that individual’s general health status, a wide practical knowledge of pharmacology, and, most important, caution (10).

Tension-Type Headache

The prevalence of tension-type headache also declines in the elderly, but not nearly as much as migraine. In community-based surveys of the elderly using the IHS criteria, the prevalence of tension-type headache ranged from 35 to 44.5% and was higher in women (31,46). Many more people had the episodic type than the chronic type. A clinic-based study in Spain reported that the most common diagnosis for headache as both the initial and main complaint in the elderly was tension-type headache (43%), possibly chronic tension-type headache (30). While most of the aged who have tension-type headache have had it since youth or middle age, they begin for the first time after the age of 50 in about 10% of tension-type headache patients (20); when this occurs, a special search should be made for concomitant and often masked depression (7,15,25,40,47).

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