Headaches in the elderly

The needs of older patients with headache often go unmet, says Dr David Kernick

Almost every individual has experienced a headache at some time during their life and for most it is infrequent and resolves either spontaneously or with simple analgesia.

However, for many, headache has a significant impact on the quality of their life and functioning.

Migraine is one of the World Health Organisation’s top 20 diseases in terms of disability impact.

There are now a number of modern agents available to treat headache, but its management remains less than ideal. The evidence suggests that the majority of those affected do not seek medical help and when they do so treatment is invariably suboptimal.

Although headache impacts mainly on individuals in their economically productive years, two groups are even less recognised and their needs are often not served.

Headache is common in the elderly, although the prevalence of headache reduces with age and the female: male ratio changes.

There are a number of specific problems in older patients with headache. An increase in co-morbidity and disease susceptibility has implications for treatment options.

Polypharmacy may mean that headaches are caused by drugs. Reduced renal and liver function may lead to altered pharmacokinetics and so increased vigilance is required when prescribing for headache.

Older patients have an increased risk of adverse drug reactions. There is a limited evidence base because few studies have been undertaken in this age group.

Primary headache

Cluster headache is less common but often remains undiagnosed. Although 10 per cent of patients affected by tension-type headache develop it after the age of 50, it becomes less frequent.

However, it can be associated with medication-overuse headache, which makes diagnosis problematic.

Migraine can develop after the age of 50 but onset is rare after the age of 60. Over the age of 50, 10 per cent will have an abnormality on imaging and so investigations should be carried out in this group.

In general, migraine has a favourable prognosis, with a decrease in prevalence from the age of 50 onwards in both sexes.

However, prevalence rates remain at 3–5 per cent, even over the age of 70.

Clinical characteristics of migraine in the elderly can change over time.

Transformation into a chronic form can occur, which can present a challenge for treatment. Migraine with aura can lose the headache element.

Often aura without headache can be confused with a visual TIA. A useful diagnostic pointer is that an aura builds up gradually whereas a TIA is of sudden onset.

Less commonly, auras can present with other sensory or motor manifestations which, in the absence of headache, can lead to diagnostic difficulties.

Migraine has a high co-morbidity with depression, which is already underdiagnosed in this age group.

Triptans are unlicensed over the age of 65 but their benefits will often be greater than the  risks, providing there are no vascular contraindications.

A large primary care study showed no increased risk for cardiac or cerebrovascular disease. However, for medico-legal purposes an ECG may be advisable.

High-prevalence headaches
Always consider temporal arteritis in a patient presenting with a headache and who is over the age of 50.

It can mimic the features of other primary headaches, although the headache gradually worsens with time. Features can include jaw claudication and constitutional symptoms.

A raised ESR is a most important indicator but can be normal in some cases.

Hypnic headache is a benign and rare disorder of the elderly. It occurs most frequently in the entire head but occasionally hemicranially. It only occurs during the night. The pain is moderate to severe and can last up to three hours. Multiple episodes during the night are rare but can occur.

Treatment options include caffeine, lithium carbonate and indometacin. The incidence of primary brain tumours is 6–10/100,000 population/year, of which 70 per cent will present in patients who are over the age of 50.

Although most patients will complain of headaches in the final stages of their disease, studies suggest an incidence at the time of diagnosis of between 23 and 56 per cent. However, the incidence of headache as a first and isolated presentation is much lower at 2–16 per cent.

A patient over 50 presenting with a headache for the first time should always be treated with caution.

Dr Kernick is a GP in Exeter 

Common causes

  • Space-occupying lesions.
  • Temporal arteritis.
  • Trigeminal neuralgia.
  • Post-herpetic neuralgia.
  • Systemic disease.
  • Parkinson’s disease.
  • Hypoxia or hypercapnia.
  • Cerebrovascular disease (thrombotic and embolic stroke — headache in 20–40 per cent, intracerebral haemorrhage
  • -headache in 80 per cent, subarachnoid haemorrhage
  • -headache in 95 per cent).
  • Cervical spondylosis.
  • Paget’s disease. 

Diagnostic criteria for hypnic headache

a)  Dull headache fulfilling criteria b–d.
b)  Develops only during sleep and wakes patient.
c)   At least two of the following characteristics:
            1)         Occurs more than 15 times a month.
            2)         Lasts more than 15 minutes after waking.
            3)         First occurs after the age of 50.
d)  No autonomic symptoms and no more than one of nausea, photophobia or phonophobia.
e)  Not attributed to any other disorder.

Source: International Headache Society

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