REVIEW

ROBERT S. KUNKEL, MD CME Consultant, Cleveland Clinic Headache Center, CREDIT Cleveland Clinic; past president, American Headache Society; past president, National Headache Foundation

Headaches in older patients: Special problems and concerns

■ ABSTRACT EADACHE IN AN ELDERLY PATIENT poses H special problems and concerns—and in Any patient older than 50 years who develops headaches the field of headache, the term “elderly” often for the first time or who has a change in a chronic means people over age 50! headache pattern should be investigated for an Age 50 may not seem so old, but it does underlying cause or exacerbating condition. Several seem to be a reasonable dividing line. The headache syndromes occur almost exclusively in older three most common headache conditions, ie, people. One of these, temporal arteritis, needs to be migraine, tension-type headache, and cluster recognized and promptly treated with corticosteroids to headache, almost always appear before age avoid permanent visual loss. Other causes of headache 45. Conversely, some headache syndromes that are more common in older people include subdural occur more commonly in older people, and a few occur almost exclusively in people older hematomas, trigeminal neuralgia, herpes zoster infection, than 50. and malignancies. Furthermore, common headache syn- ■ dromes are often associated with concomi- KEY POINTS tant medical conditions in this age group, Migraine rarely arises initially in older people, and attacks which may cause problems in management. Headaches that are secondary to other dis- tend to diminish with age. However, migraine auras eases (including malignancies) are much without headache may become more common in people more common in older people. Many elderly with a history of migraine and must be distinguished people also take multiple medications, some from ischemic attacks. of which can cause headaches. For these reasons, any headache occurring Tension headaches can arise from a number of age- for the first time in someone over the age of 50, related causes, including arthritis, degenerative changes, or a changing headache pattern in a patient visual abnormalities, and ill-fitting dentures. with chronic headaches, necessitates a com- plete evaluation to look for an underlying cause. Subdural hematoma can develop even without direct ■ head trauma or, gradually, several weeks after mild MIGRAINE TENDS trauma. TO DIMINISH WITH AGE Migraine rarely occurs for the first time after Trigeminal neuralgia causes waves of sharp pain age 40. An older person who presents with the triggered by touching the face, laughing, or chewing. new onset of migraine should be evaluated for “symptomatic migraine,” meaning a migraine- Patients presenting with headache should have their type headache due to an underlying condition. medication list reviewed: a number of common drugs can Usually, migraine attacks become less fre- cause headache. quent and milder over the years, and associat- ed problems, such as nausea and general dis-

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Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. TABLE 1 Distinguishing migraine-associated symptoms from ischemia-associated symptoms

SYMPTOMS MIGRAINOUS ISCHEMIC

Visual Bright, shimmering Dark, dim Both visual fields Unilateral Moving shapes Static 15–60 minutes in duration 2–5 minutes in duration Paresthesias Come on gradually Arise suddenly Area involved first clears last Symptoms develop and clear in same order 20–30 minutes in duration 5–10 minutes in duration

ability, tend to diminish. Most women with tends to last for 20 to 30 minutes and then hormonally triggered migraine have few clears in the reverse order. In contrast, attacks after menopause. ischemic paresthesias tend to arise suddenly, On the other hand, migraine variants last only 5 to 10 minutes, and clear in the such as migraine aura without headache, total same order they developed. global amnesia, and transient migrainous Total global amnesia lasts 1 to 3 hours, accompaniments occur more commonly in during which the patient functions and acts older patients with a history of migraine.1,2 normally, with no other neurologic deficit, but afterward cannot recall anything that hap- Distinguishing migraine aura pened. Total global amnesia was once thought from ischemic attacks to be an epileptic disorder but is now believed It is important to distinguish between visual or to be migrainous. Migraine neurologic symptoms associated with migraine rarely occurs (ie, auras, which may occur without a subse- Treating migraine in older people quent headache) and those associated with Triptans and ergotamines are vasoconstrictors for the first ischemic disease (TABLE 1). Cerebral vascular and should be used cautiously in older time after disease, clotting disorders, and embolic phe- patients. They are contraindicated in patients nomena must be excluded in patients with with uncontrolled hypertension or evidence of age 40 episodic visual or neurologic symptoms. cerebral, coronary, or peripheral vascular dis- Visual symptoms associated with ease, but they appear to be safe in patients migraine aura tend to evolve slowly and last without evidence of significant vascular dis- from 15 minutes to 1 hour. The visual abnor- ease. Hall et al,3 in a study of 13,664 patients malities seem to enlarge, grow, move across with migraine with prescriptions for triptans, the visual field, and then clear. They tend to found no increased risk of stroke, myocardial be “positive” (bright and shimmering), may infarction, cardiovascular death, ischemic take on various designs, and are homonymous heart disease, or death compared with (occur in both visual fields). matched controls without migraine.3 In contrast, the visual defects of transient Preventive drugs (ie, those that are taken ischemic attacks are usually dark, dim, and sta- on a regular schedule to prevent migraine tic. Symptoms tend to last for only a few min- attacks, such as calcium channel blockers, utes and are usually unilateral because one of beta-blockers, anticonvulsants, antidepres- the carotid arteries is more narrowed than the sants, and nonsteroidal anti-inflammatory other. drugs [NSAIDs]), may be effective at lower Paresthesias due to migraine (transient doses in older patients. migrainous accompaniments) tend to spread Patients who use NSAIDs long-term slowly up or down the extremities. Tingling should be closely monitored for azotemia,

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TABLE 2 irritated from disease in the upper cervical spine. An occipital nerve block should pro- Possible causes of tension- vide relief. type headache in the elderly Degenerative changes at any level, how- Anxiety, stress ever, can irritate the cervical muscles, causing Depression spasm, local tenderness, and limited range of Cervical spondylosis motion. Poor posture with slouching, rounded Poor posture shoulders, and a forward-positioned head are Temporomandibular joint disorders common in the elderly and may cause pain Degenerative arthritis in the joint from strain, spasm, and tightness in the cervi- Malalignment of the bite cal muscles. Clenching, bruxism Uncorrected refractive errors Treatment of tension headache Overuse of analgesics (rebound headache) in the elderly Endocrine disorders Physical therapy with exercises for range of motion, posture, and balance may help some patients with neck and head pain and may worsening of hypertension, or enhanced cere- lessen the need for medications. If stress is an bral or coronary artery disease. The newer important factor, relaxation techniques, cyclooxygenase-2 inhibitors cause less gastric biofeedback, and stress management skills irritation and are often very effective in easing may help. the pain of migraine but have either been Preventive medications for tension-type removed from the market or have been great- headache such as tricyclic antidepressants, ly restricted because of the increased risk of muscle relaxants, and NSAIDs should be used stroke and coronary events due to their block- with caution in the elderly because of possible ing the effects of prostaglandins.4 sedation and other side effects. Migrainous auras that occur without Rebound headache or analgesic-main- Consider headache are usually infrequent and do not tained headache can occur when analgesics rebound require treatment. are used daily or near-daily. In a vicious circle, these medications are believed to suppress headache ■ TENSION-TYPE HEADACHE endogenous endorphins and sensitize neurons, in anyone CAN BE DUE TO AGE-RELATED CAUSES so that headache recurs when blood levels drop.6 Rebound headache should be consid- who wakes Tension-type headache usually appears before ered in anyone who wakes every morning every morning age 45, but can develop later due to a number with a headache. with a of age-related factors, alone or in combination (TABLE 2).5 As in younger patients, stress and ■ CLUSTER HEADACHE headache depression are the most common causes. However, in older people, excessive muscle Cluster headache, like migraine, tends to be tension in the neck, scalp, and face may be less of a problem as one grows older, as the caused or aggravated by cervical arthritis, poor attacks tend to come further apart with longer posture, visual abnormalities, and temporo- remissions as one ages. mandibular joint disorders. Spasm in the tem- The usual preventive medications for poromandibular muscles may be due to teeth- cluster headache—verapamil, lithium, and clenching, arthritis in the joint, or an abnor- antiepileptic drugs—can safely be used in mal bite because of ill-fitting dentures. most older people. On the other hand, pro- Degenerative arthritis in the cervical longed treatment with prednisone, which is spine is common in the elderly but rarely caus- usually very effective against cluster es headache unless there is nerve root irrita- headache, can accelerate osteoporosis, elevate tion at the C1 through C3 levels. Tenderness blood sugar levels, and cause easy bruising and over the occipital neurovascular bundle sug- gastric complications. gests that the roots of the occipital nerve are Vasoconstrictive drugs for alleviating

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Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. acute attacks should only be used with caution Branches of the aorta and the coronary arter- in patients at risk for vascular disease. Oxygen ies may also be involved.10 It is thought that by mask is usually well tolerated and may be injury to the elastic lamellae invokes an quite effective in aborting cluster headache inflammatory response of lymphocytes, plasma attacks.7 cells, macrophages, and giant cells. Visual loss occurs due to ischemia of the retina or the ■ HYPNIC HEADACHE OCCURS optic nerve (or both) from inflammation in MOSTLY IN OLDER PEOPLE the vessel wall, which results in narrowing of the lumen of the ciliary arteries or the central Hypnic headache is a very uncommon prima- retinal artery.11 ry headache syndrome of unknown cause that occurs mostly in older people. Pain awakens Biopsy required for diagnosis the patient at about the same time each night The combination of a recent onset of and lasts for about 1 to 2 hours. The pain is headache and an elevated erythrocyte sedi- usually located in the frontal area of the head mentation rate (ESR) strongly suggests tem- and is described as a steady discomfort. The poral arteritis. ESR values performed by the parasympathetic symptoms that commonly Westergren method are usually more than 60 accompany cluster headache are absent. mm/hour in patients with temporal arteritis, Hypnic headache is usually self-limited and often over 80 mm/hour. An elevated C- and may ease after a few months. Lithium car- reactive protein level is also very common, as bonate, a tricyclic antidepressant, or an is a mild normocytic and normochromic ane- antiepileptic drug taken at bedtime usually pre- mia. vents attacks. NSAIDs may also be effective.8 However, temporal artery biopsy is needed to confirm the diagnosis, and should be done ■ TEMPORAL ARTERITIS: if the condition is suspected even if acute- A TRUE HEADACHE EMERGENCY phase reactant levels are normal. A fairly long segment of artery should be taken for biopsy Temporal arteritis, also known as giant cell because the inflammatory process may be Untreated, arteritis, occurs almost exclusively in older intermittent. If the biopsy findings are nega- 20% - 30% people and should be considered in anyone tive and the history, physical examination, over 50 who presents with a new onset of and laboratory results are characteristic of of patients headache. It is one of the few headache emer- temporal arteritis, a biopsy of the other tem- with temporal gencies: permanent loss of vision occurs in poral artery should be considered. 20% to 30% of patients without treatment. arteritis have Stroke is uncommon but may occur.9 Start prednisone immediately permanent loss The pain is typically a steady ache or a if temporal arteritis is suspected of vision dull throbbing discomfort in the temples but If temporal arteritis is suspected, prednisone can be of other types and involve any area of 60 to 80 mg/day should be started immediate- the head. In addition, this is a systemic condi- ly, even if a biopsy has not yet been done; a tion, and many patients present with fatigue few days of treatment will not significantly and low-grade fever. They may have stiff and alter the pathological findings. If the biopsy painful proximal muscles, especially in the findings are negative and the history and morning. Scalp tenderness is common, and physical examination do not strongly suggest the temporal artery is often thickened and the condition, prednisone should be tapered tender with a diminished or absent pulse. Pain and discontinued. with chewing (jaw claudication) is quite spe- The headache of temporal arteritis cific for this condition but is uncommon. responds quickly and dramatically to high doses of prednisone, as does the ESR. In con- Temporal arteritis is autoimmune trast, a headache caused by another condition Temporal arteritis is an autoimmune disorder is not likely to fully respond to prednisone. that causes systemic, necrotizing granuloma- Corticosteroid therapy should continue tous inflammation of medium-sized arteries. for several months and sometimes for a year or

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more until the process heals. Patients should who use sedatives or abuse alcohol are more be followed clinically and with laboratory prone to falls, making head injuries more like- tests while prednisone is very gradually ly. Those taking daily aspirin or anticoagu- tapered over several months. lants may develop a subdural hematoma with Visual loss and other complications occa- minimal head injury. sionally occur during therapy but are very Bleeding is usually caused by rupture of a uncommon after 4 to 6 weeks of high-dose bridging vein, and symptoms may not develop corticosteroid therapy. After a few months of for several days or even weeks.15 Headache is treatment, most patients can be maintained usually dull, mild, and generalized. Other on prednisone 10 to 20 mg/day. symptoms may include drowsiness, confusion, Long-term use of corticosteroids in older and personality changes, but focal or localiz- people is likely to cause gastric complications, ing neurologic signs are unusual. hyperglycemia, and osteoporosis, all of which Subdural hematoma is diagnosed with need to be monitored and treated if necessary. magnetic resonance imaging or computed Calcium supplementation, vitamin D, and tomography with or without contrast. Most bisphosphonate therapy may be needed. small hematomas resolve without surgical intervention and warrant observation only. Adjuvant treatments Patients with a large hematoma with signifi- Some studies have found that methotrexate, cant brain compression or who have confu- cyclophosphamide, and other immunosup- sion and drowsiness require prompt surgical pressive agents combined with prednisone drainage. may help reduce the amount and duration of prednisone needed and the number of relaps- ■ TRIGEMINAL NEURALGIA es.12,13 However, a similar study found no ben- OCCURS MOST OFTEN IN ELDERLY efit to adjuvant methotrexate treatment.14 Ninety percent of cases of trigeminal neural- Polymyalgia rheumatica sometimes gia occur in people older than 40 years. In a In older people, accompanies temporal arteritis younger person, trigeminal neuralgia is usual- subdural Polymyalgia rheumatica, a low-grade inflamma- ly caused by a neurologic disease, such as mul- tory condition of muscles, is sometimes associ- tiple sclerosis, an intracranial neoplasm, or an hematomas ated with temporal arteritis. It causes diffuse infection.16 can develop muscle aching and stiffness, which are especial- In the usual idiopathic variety, the second ly prominent in the proximal muscle groups. and third divisions of the trigeminal nerve, ie, after minor The stiffness and pain are worse at night and the maxillary and the mandibular nerves, are trauma or upon awakening. Headache alone is usually not most often affected. Headache is unilateral, even vigorous a prominent feature. The ESR is usually elevat- sharp, and jabbing and occurs in a repetitive, ed, and mild anemia may be present. crescendo, wave-like pattern lasting a few sec- sneezing Prednisone in the high doses used for tem- onds. Pain can be triggered by touching or poral arteritis will control the symptoms of stimulation of the face, eg, from shaving, polymyalgia rheumatica as well. If the patient chewing, laughing, or brushing teeth. has only polymyalgia rheumatica without Trigeminal neuralgia is sometimes confused temporal arteritis, low doses of prednisone with cluster headache, but the latter is not (5–20 mg/day) are adequate. triggered by touching the face and involves steady pain for 30 to 120 minutes with each ■ SUBDURAL HEMATOMA attack. IS MORE COMMON IN ELDERLY Trigeminal neuralgia can be caused by compression of the root of the fifth cranial Subdural hematomas occur much more fre- nerve by an artery in the posterior fossa, by an quently in older people. A hematoma can irritation of the gasserian ganglion, or by an develop after a minor head trauma, falling irritation of any of the three divisions of the with no direct head trauma (jolt effect), or trigeminal nerve. A prior viral infection even vigorous sneezing or coughing. People involving the nerve may be a factor.17

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Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. Treated with anticonvulsants, surgery TABLE 3 Carbamazepine, gabapentin, pregabalin, baclofen, topiramate, or other anticonvulsant Medications that can drugs are usually effective in controlling symp- cause headache toms of trigeminal neuralgia. Vasodilating drugs Surgery should be considered if medica- Diltiazem tion does not control pain. The gasserian gan- Hydralazine glion can be effectively treated with radiofre- Isosorbide quency waves or glycerol instillation. The Minoxidil trigeminal root entry zone can be treated with Nifedipine gamma knife irradiation.18 Posterior cranioto- Nitroglycerine Prazosin my to relieve pressure on the nerve from an Verapamil arterial loop can be effective but is rarely nec- essary. Nonsteroidal anti-inflammatory drugs Diclofenac ■ Indomethacin HERPES ZOSTER Piroxicam Herpes zoster is caused by reactivation of dor- Others mant varicella virus in a nerve ganglion, Cyclosporine Danazol which may be triggered by altered immunity Estrogens from chronic illness or by the use of cortico- Histamine2-receptor antagonists steroids or other immunosuppressive drugs. Sulfa drugs, tetracyclines The face is affected if the gasserian gan- Tamoxifen glion is involved. Eye pain can be severe, and visual loss may occur. Pain may precede vesic- ular lesions by several days. Early treatment with acyclovir, famciclovir, or valacyclovir Sleep apnea with either hypoxia or hyper- may help reduce the pain and rash, and may carbia may cause headache upon awakening Intracranial also prevent involvement of the cornea.19 and generally eases after the patient gets up neoplasms Postherpetic neuralgia is pain that persists and moves around. for more than 3 months after the lesions have Endocrine abnormalities such as hypo- can cause healed. It tends to be more common in older thyroidism, hyperthyroidism, and hypercal- headache, but people and may occur in up to 50% of those cemia can cause headaches. Hypoglycemia can afflicted in their 60s and 70s. Amitriptyline, cause headache but is also associated with neurologic nortriptyline, gabapentin, and pregabalin may other symptoms, such as sweating, palpitations, symptoms help control the pain. Tricyclic antidepressants and hunger. are more should be used only with caution in older Malignancies are more prevalent in older patients because of anticholinergic effects. people and need to be considered in anyone with troublesome the new onset of headache. Headache can be ■ OTHER MEDICAL CONDITIONS caused by primary brain tumors or brain metas- THAT CAN CAUSE HEADACHE tases, especially from breast or lung cancer. Intracranial neoplasms tend to cause neu- Headache can be secondary to a number of rologic symptoms that are more troublesome medical conditions. than the headache. Headache is usually not Hypertension. Hypertensive headache severe or localized. A large lesion may obstruct may occur if the diastolic pressure is consis- cerebrospinal fluid flow and cause a positional tently higher than 120 mm Hg. The pain typ- component to the pain. ically is generalized, throbbing, and worse Infections involving any area of the head, upon awakening and tends to ease with activ- including the sinuses and teeth, may be asso- ity. Migraine is commonly exacerbated by only ciated with headache, as can systemic infec- mildly elevated blood pressure (diastolic levels tions with or without sepsis. Examination 90–110 mm Hg). should reveal evidence of infection in the

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involved areas. ■ MEDICATIONS THAT CAN CAUSE Acute glaucoma may be associated with HEADACHE severe periorbital pain that comes on abruptly and is accompanied by visual blurring and red- Elderly people tend to take multiple medica- ness of the eye. tions. It is important to thoroughly review a Other conditions. Connective tissue dis- patient’s drug list, especially when he or she eases, anemia, polycythemia, thrombocytosis, presents with a new headache or a different and electrolyte abnormalities may cause or pattern, or if the medications have recently exacerbate headaches. changed. Commonly used medications that can cause headache are listed in TABLE 3.

■ REFERENCES phamide pulses. J Intern Med 1992; 232:373–375. 1. Fisher CM. Late-life migrainous accompaniments—further experi- 13. Jover JA, Hernandez-Garcia C, Morado IC, Vargas E, Benares A, ence. Stroke 1986; 17:1033–1042. Fernandez-Gutierrez B. Combined treatment of giant-cell arteritis 2. Kunkel RS. Migraine aura without headache: benign, but a diagnosis with methotrexate and prednisone: a randomized, double-blind, of exclusion. Cleve Clin J Med 2005; 72:529–534. placebo-controlled trial. Ann Intern Med 2001; 134:106–114. 3. Hall GC, Brown MM, Mo J, MacRae KD. Triptans in migraine: the risks 14. Hoffman GS, Cid MC, Hellmann DB, et al; International Network for of stroke, cardiovascular disease, and death in practice. Neurology the Study of Systemic Vasculitides. A multicenter, randomized, dou- 2004; 62:563–568. ble-blind, placebo-controlled trial of adjuvant methotrexate treat- 4. Mukherjee D, Nissen SE, Topol EJ. Risk of cardiovascular events asso- ment for giant cell arteritis. Arthritis Rheum 2002; 46:1309–1318. ciated with selective COX-2 inhibitors. JAMA 2001; 286:954–959. 15. Auers LM. Epidural and subdural hematomas. In: Vinken PJ, Bruyn 5. Solomon GD, Kunkel RS Jr, Frame J. Demographics of headache in GW, Klawans HL, editors. Vascular Diseases. Handbook of Clinical elderly patients. Headache 1990; 30:273–276. Neurology, Part II, vol 54. Amsterdam: Elsevier, 1989:345–360. 6. Diener H-C, Tfelt-Hansen P. Headache associated with chronic use of 16. Rozen TD, Capobianco DJ, Dalessio DJ. Cranial neuralgias and atypi- substances. In: Olesen J, Tfelt-Hansen P, Welch KMA, editors. The cal face pain. In: Silberstein SD, Lipton RB, Dalessio DJ, editors. Headaches. New York: Raven Press; 1993:721–727. Wolff’s Headache and Other Head Pain. 7th ed. New York: Oxford 7. Fogan L. Treatment of cluster headache. A double-blind comparison University Press; 2001:509–524. of oxygen v air inhalation. Arch Neurol 1985; 42:362–363. 17. Terrence CF, Jensen TS. Trigeminal neuralgia and other facial neural- 8. Dodick DW, Mosek AC, Campbell JK. The hypnic (“alarm clock”) gias. In: Olesen J, Tfelt-Hansen P, Welch KM, editors. The Headaches. headache syndrome. Cephalalgia 1998; 18:152–156. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:929–938. 9. Caselli RJ, Hunder GG, Whisnant JP. Neurologic disease in biopsy- 18. Young RF, Vermeulen SS, Grimm P, Blasko J, Posewitz A. Gamma proven giant cell (temporal) arteritis. Neurology 1988; 38:352–359. knife radiosurgery for treatment of trigeminal neuralgia: idiopathic 10. Ostberg G. Morphological changes in the large arteries in polymyal- and tumor related. Neurology 1997; 48:608–614. gica arteritica. Acta Med Scand Suppl 1972; 533:135–139. 19. Kost RG, Straus SE. Postherpetic neuralgia—pathogenesis, treat- 11. Hayreh SS. Posterior ischemic optic neuropathy. Ophthalmologica ment, and prevention. N Engl J Med 1996; 335:32–42. 1981; 182:29–41. 12. de Vita S, Tavoni A, Jeracitano G, Gemignani G, Dolcher MP, ADDRESS: Robert S, Kunkel, MD, Headache Center, T33, Cleveland Clinic, Bombardieri S. Treatment of giant-cell arteritis with cyclophos- 9500 Euclid Avenue, Cleveland, OH 44195; e-mail [email protected].

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