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General Principles 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

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 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.

Differential Diagnoses

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, ...

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