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GENERAL PRINCIPLES

In the headache literature, the term older adult usually refers to patients age 50 years and older because of changes in presentation and types of headache that occur in patients older than age 50. Primary headaches tend to abate, whereas secondary headaches, that is, headaches caused by another disease or medical condition, become more common with age. Up to 30% of headache complaints in the older adult are caused by other etiologies, including medical conditions or their associated treatments. Essentials to consider when assessing headaches in older adults include the following:

  • New-onset headaches are rare in older adults and necessitate evaluation.

  • Temporal arteritis is an emergency.

  • Headaches in older adults are frequently due to an underlying medical diagnosis or treatment.

GENERAL EVALUATION

Development of a new headache in an older adult or a change in pattern of chronic headaches warrants a thorough medical evaluation. This should include a detailed clinical history with review for red flag symptoms (systemic symptoms such as fevers, chills, myalgias, weight loss; focal neurologic findings; onset >50 years old; thunderclap headache onset; papilledema; positional headache; headache precipitated by Valsalva maneuver or exertion; progressive headache and/or headache with pattern change), complete pharmacologic review, and comprehensive neurologic examination. Additional workup may be necessary in the older adult, as new headaches are more often a result of serious conditions or exacerbations of comorbid disorders. Such workup may include brain imaging with computed tomography (CT) and/or magnetic resonance imaging (MRI) to evaluate for space-occupying lesions; cervical spine radiography to evaluate for facet disease causing cervicogenic headache; arterial imaging in the setting of ischemic headache symptoms; laboratory testing, including a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and a complete metabolic panel; overnight oximetry in cases of morning headaches or to evaluate for nonrestorative sleep; and/or referral to ophthalmology to evaluate for vision impairment, glaucoma, or other ocular causes of headache.

DIFFERENTIAL DIAGNOSES

A. Primary Headache

The three most common primary headache types (migraine, tension, and cluster) usually have onset before age 45 years. Generally, the presentation and management of these headaches are similar in younger and older adults; however, some unique features found in headaches in older adults are outlined below.

1. Migraine

a. General considerations

Approximately 6% of adults older than the age of 50 years experience migraine type headaches, and new-onset migraine in older adults accounts for approximately 3% of all migraine sufferers. Typically, older adults with a history of migraine experience fewer and milder migraines as they age. Traditional migraine should be differentiated from aura without migraine, which used to be called late life migraine accompaniments. Only 40% to 50% of patients with aura without migraine will go on to develop a typical migraine headache.

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