60: Treating Headaches in Older Adults

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:

• New onset headaches are rare in older adults necessitating evaluation

• Temporal arteritis is an emergency

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

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 complete pharmacologic review and comprehensive neurologic examination. Additional work-up may be necessary in the older adult, as new headaches are more often a result of serious conditions or exacerbations of comorbid disorders. Such work-up may include brain imaging with CT and/or MRI; 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.

Primary Headache

The 3 most common headache types (migraine, tension, and cluster) usually have onset before age 45 years. Generally, the presentation and management of these headaches is similar in younger and older adults; however, some unique features found in headaches in older adults are outlined below.

Migraine

General considerations—

New-onset migraine in adults older than the age of 50 years occurs in 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 acephalic migraine (migraine without headache).

Acephalic migraine often begins after the age of 40 years, following a migraine-free period of many years or in the absence of a history of migraine. The overall course is benign, and patients experience predominantly visual symptoms. Other symptoms include migrating paresthesia, speech disturbance, and progression of 1 neurologic symptom to another. Most patients experience 2 or more identical spells, each lasting 15–25 minutes.

Clinical findings—

Migraine attacks in the older adult are less typical compared with younger individuals. They are more frequently bilateral and have fewer associated symptoms, such as photophobia, phonophobia, nausea, and vomiting; thus they may be misdiagnosed as tension-type headache. Patients may complain of throbbing pain, aura, and traditional triggering and ameliorating factors. Attacks are also more often associated with vegetative symptoms, such as anorexia, dry mouth, and paleness.

Acephalic migraine is more common in people with a history of migraine. Visual symptoms (scintillations, diplopia, oscillopsia, nystagmus) associated with migraine aura tend to evolve slowly. Patients describe bright shimmering lights that tend to enlarge and move across both visual fields before they disappear. These symptoms may raise concern for a transient ischemic attack (TIA). However, in TIA, visual deficits tend to be dark, dim, and static lasting only a few minutes. Paresthesias from migraine usually move up and down the extremities, may be bilateral, and clear in the reverse order. Ischemic paresthesias tend to occur suddenly, clear in the same order as they developed, and 90% last less than 15 minutes.

Menopause has variable effects on migraine. Two-thirds of women with migraine will experience a marked improvement, or complete cessation, once they are completely menopausal. Women who require hormonal therapy may have an increase in headache frequency secondary to therapy. Reducing the dose of estrogen or changing the type of estrogen from a conjugated estrogen to pure estradiol may reduce the number of headaches. The favorable course of migraine postmenopause is primarily attributed to the absence of variations in sex hormone levels.

Evaluation—

Because of the clinical overlap between acephalic migraine and TIA, stroke imaging, such as brain MRI, is warranted. Vessel imaging, such as a CT or magnetic resonance angiogram, may also be considered to evaluate vascular risk factors.

Treatment—

Because of their vasoconstrictive effects, abortive agents, such as triptans and ergotamines, should be used cautiously in older adults. They are contraindicated in patients with uncontrolled hypertension or evidence of vascular disease. Effective abortive agents include the limited use of acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and opioid analgesics. Patients on NSAIDs chronically should be monitored for azotemia, hypertension, or worsening cerebral or coronary artery disease. Tricyclic antidepressants (TCAs), such as amitriptyline and nortriptyline, are often used for migraine prevention, however, these are not a first-line choice in older individuals because of their anticholinergic side effects. Calcium channel blockers and β blockers also may be used for prevention, and are often effective at lower doses.

Tension headache

General considerations—

Tension headaches typically begin before age 45 years and are most commonly caused by physical or psychological stress. However, these headaches can develop later in life secondary to age-related musculoskeletal, visual, or dental changes.

Clinical findings—

Neck spasms, cervical spine and muscle tenderness, or decreased cervical range of motion, all of which can be caused by spinal degenerative changes irritating the cervical muscles, may be present. Additionally, some patients complain of spasms of the temporomandibular joint (TMJ), from teeth-clenching, arthritis in the joint, or an abnormal bite. Cervical nerve root irritation can also occur, resulting in complaints of tenderness over the occipital neurovascular bundle, suggesting occipital nerve involvement.

Evaluation—

Physical exam should include evaluation for muscle tension in the neck, scalp, and face, and an assessment of the patients posture. Attention to the patients bite and screening for TMJ disorders should be performed. Imaging may be warranted if there are concerns for cervical arthritis.

Treatment—

Nonpharmacologic therapies include physical therapy for posture, balance, and range of motion in patients with musculoskeletal causes; referral to optometry or ophthalmology in the setting of decreased vision or eye strain; and relaxation therapy when stress is identified as a primary trigger.

Pharmacologic therapies include TCAs, muscle relaxants, and NSAIDs in younger populations, but should be used with caution in older patients because of the adverse side-effect profile. Acetaminophen can be used safely in older patients and should be considered prior to other agents. Nerve blocks may be indicated in settings of nerve root pain.

Cluster headache

General considerations—

Cluster headaches are less of a problem in older individuals, with a decrease in the frequency of attacks. The etiology of these headaches is not completely understood, however, there appears to be genetic links and frequently patients are smokers.

Clinical findings—

Cluster headaches typically are episodic, severe headaches of the orbital, supraorbital, or temporal area. Associated autonomic symptoms include ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion occurring ipsilateral to the side of pain. Characteristically, they are of short duration (15–180 minutes) and unilateral, yet symptoms may switch to the other side during a different cluster attack. Patients may describe feeling restless or the need to pace during an attack.

Evaluation—

Cranial imaging is recommended with CT or MRI to exclude structural brain lesions, including pituitary abnormalities.

Treatment—

Abortive therapy with oxygen is usually safe and effective. Oxygen therapy should be used cautiously in patients with severe chronic obstructive pulmonary disease given risk of severe hypercapnia and CO₂ narcosis. Vasoconstrictive drugs, such as triptans, have been shown to be effective, but should be used cautiously in patients with vascular disease because of deleterious side effects. One should consider giving first doses in a monitored setting. Even though often effective, prednisone should be used cautiously as it can worsen other medical conditions, such as osteoporosis and diabetes. Preventative medications, such as verapamil, lithium, and antiepileptic drugs, can usually be safely used in older adults.

Hypnic headache

General considerations—

Hypnic headache syndrome is a rare, benign, recurrent, sleep-related headache disorder that occurs almost exclusively in patients older than 50 years. Painful attacks awaken patients from sleep at a predictable time, often during rapid eye movement stages, and can last from 15 minutes to 2 hours occurring, 1–2 times per night.

Clinical findings—

Hypnic headaches are not accompanied by autonomic symptoms, differentiating them from cluster headaches. Pain is most often described as bilateral, as opposed to the unilateral location of cluster headaches. Patients describe the pain as a steady discomfort primarily in the frontal area.

Evaluation—

Diagnosis is based on history and further evaluation is usually not indicated.

Treatment—

Hypnic headaches are self-limited and may resolve after a few months. In the case in which medication therapy is needed, lithium carbonate has shown a favorable response. TCAs, antiepileptics, or NSAIDs at bedtime may also be effective. The side-effect profile of lithium often precludes use in older patients. At least 1 prospective study has shown that hypnic headaches may be responsive to indomethacin. In the older adult, caffeine and melatonin are often effective, safer options.

Secondary Headache

Temporal arteritis (Giant cell arteritis)

General considerations—

Also known as giant cell arteritis (GCA), temporal arteritis is a systemic necrotizing vasculitis occurring primarily in whites and has a female predominance. GCA typically occurs in 70–80-year-olds, but should be considered in patients older than 50 with new-onset headache. It is a medical emergency and may result in permanent visual loss in 15% to 20% of patients.

Clinical findings—

The first symptom in 70% to 90% of patients is a steady or throbbing headache over the temples. However, pain may involve any portion of the head or scalp and may come in waves, triggered by touching the face, laughing, or chewing. Visual symptoms may include amaurosis fugax, diplopia, and visual loss. Symptoms consistent with polymyalgia rheumatica are present in approximately 66% of patients. Nonspecific symptoms of fatigue, anorexia, low-grade fever, and weight loss may also be present. The temporal artery is often thickened with a diminished or absent pulse, and may be tender to palpation. Jaw claudication is uncommon but is highly specific for temporal arteritis.

Evaluation—

Temporal artery biopsy is the gold standard for diagnosis. Classic findings consistent with GCA, granulomatous inflammatory infiltrate with giant cells located at the intima-media junction, are only found in 50% of cases. Ideally, biopsy should be done within 48 hours of initiating treatment. If elevated, CRP and ESR have 97% specificity in diagnosing GCA. Pulses may be diminished and palpation of carotid, brachial, radial, femoral, and pedal pulses is recommended. Funduscopic exam by an ophthalmologist is warranted.

Treatment—

To prevent blindness, urgent treatment with systemic steroids is the standard of care. Even if temporal artery biopsy is not immediately available, treatment should be initiated because pathologic findings may be present for up to 2 weeks after steroid administration. Usual course includes 1 month of full-dose therapy, followed by a slow taper up to 1–2 years. Intravenous glucocorticoids may be recommended for patients at high risk of blindness.

Cerebral vascular disease

General considerations—

Headache can be the heralding symptom in up to 50% of hemorrhagic strokes and 25% of ischemic strokes. In older adult patients with vascular risk factors and headache, cerebrovascular disease must be considered. See Chapter 23, “Cerebrovascular Disease.”

Trigeminal neuralgia

General considerations—

Trigeminal neuralgia (TN) is one of the most common neuralgias seen in older adults, with the incidence increasing with age, and slight female predominance. Classic TN occurs in 80% to 90% of cases, and is thought to be caused by compression of the trigeminal nerve root by an aberrant arterial or venous loop. Secondary TN may be a result of other causes, such as an acoustic neuroma, meningioma, epidermoid cyst, or, rarely, an aneurysm or arteriovenous malformation.

Clinical findings—

Patients may experience paroxysmal attacks of unilateral sharp, superficial or stabbing pain in the distribution of 1 or more branches of the fifth cranial nerve. Pain is often described as “electric” or “shock-like” and is maximal at onset of an attack. The pain may last only minutes, but often returns in repeated attacks, and usually does not awaken patients from sleep. Episodes may last for weeks to months and may be followed by pain-free intervals. Patients may develop a general dull ache in the distribution of the affected nerve.

Evaluation—

TN is a clinical diagnosis. Attacks may be triggered during an examination by touching the “trigger zone,” usually an area in the distribution of the affected nerve, often near the midline. Actions that may trigger an attack include chewing, talking, brushing one’s teeth, cold air against the face, smiling, or grimacing. International Headache Society Diagnostic Criteria for TN are:

1. Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting 1 or more divisions of the trigeminal nerve.

2. Pain that has at least 1 of the following characteristics: intense, sharp, superficial, or stabbing; or pain that is precipitated from a trigger area or by trigger factors.

3. Stereotyped attacks in an individual patient.

4. No clinically evident neurologic deficit.

5. No other attributing disorder.

Notably, secondary TN is often indistinguishable from classic TN. Imaging with CT or MRI is warranted to rule out secondary causes. Electrophysiologic tests may be useful in distinguishing classic from secondary causes of TN.

Treatment—

Pharmacologic therapy is the initial treatment for patients with classic TN. Carbamazepine is the best studied and side effects may be manageable if it is started at low doses with slow titration. Oxcarbazepine is probably effective, along with baclofen, lamotrigine, and pimozide. There is less evidence for the effectiveness of clonazepam, gabapentin, phenytoin, tizanidine, and valproate. Periodic taper or withdrawal trials should be attempted. Secondary TN requires treatment of the underlying condition, however, medications used in treatment of classic TN may provide pain relief. In patients with refractory pain, microvascular decompression or ablative surgical procedures may be considered.

Mass lesions

General considerations—

Older adults have a higher incidence of intracranial tumors than younger adults. Up to 50% of patients presenting with brain tumors complain of headache.

Clinical findings—

Pain is usually generalized, but may be localized over the tumor. The classic severe morning headache, associated with nausea and vomiting, occurs in approximately 17% of patients. More often, patients complain of symptoms similar to tension or migraine headache.

Evaluation—

If a mass lesion is suspected, an MRI must be obtained and subspecialty referral pursued.

Treatment—

Neurosurgical, medical, and/or palliative care options should be considered.

Cervicogenic headache

General considerations—

Cervicogenic headache is referred pain from anatomic structures and soft tissues of the neck. This headache type may be overdiagnosed in the older adult secondary to the large number of geriatric patients with radiographic changes consistent with cervical spondylosis.

Clinical findings—

Symptoms are elicited by neck movement, certain head positions, or when pressure is applied over cervical musculature. There may be occipital-nuchal pain, limited range of motion of the neck, or spasms of the cervical muscles.

Evaluation—

Successful anesthetic blockade of the cervical facet joint, nerve root, or occipital nerves is confirmatory.

Treatment—

Nonpharmacologic therapies include neck massage, physical therapy, and biofeedback. Muscle relaxants and NSAIDs may be necessary but used with caution in the older adult. Procedural treatments include radiofrequency facet joint rhizolysis and occipital nerve cryorhizolysis.

Medication-induced headache—

Medications and supplements should be reviewed as a cause of headache. Common offenders include nitrates, calcium channel blockers, estrogens/progestins, histamine blockers, theophylline, and NSAIDs. Overuse, or abrupt discontinuation, of caffeine, analgesics, narcotics, and serotonin antagonists can lead to daily headache. A careful history regarding the timing of headaches in relation to starting or taking a medication is advised.

Headache caused by other medical conditions—

Older adults often have medical conditions or treatments that may cause or worsen headaches, which should be considered in the differential diagnosis.