Donald F. Weaver R. Allan Purdy The Gernatric : A Unique Clinical Ailment SUMMARY SOMMAIRE The "geriatric headache" may be a unique La < ce'phalee geriatrique )) peut s'averer une affection clinical ailment. A change in a chronic clinique unique. Un changement dans les caracteristiques d'une cephalee chronique ou headache pattern or a new onset headache l'apparition d'un nouvelle cephalee devrait should raise suspicion immediately in an immediatement reveiller les soupqons chez le patient elderly patient. Temporal occurs age. L'arterite temporale se manifeste presque alnost exclusively in the elderly population. exclusivement chez les personnes agees. A cause de Because of its grave prognosis and ease of son pronostic sombre et sa facilite de traitement, il this condition should always be faut toujours soupconner la possibilite de cette treatment, condition chez le patient age souffrant de cephalee. considered a possibility in the elderly patient Une cephalee lancinante non migraineuse peut with headache. A throbbing non-migranous laisser presager la menace d'un accident headache may indicate an impending cerebrovasculaire. D'autres causes de cephalee, cerebrovascular event. Other causes of telles les lesions expansives (tumeurs, hematomes headache, such as mass lesions (tumours, sous-duraux), les medicaments (nitrates, estrogenes) et la d6pression prennent davantage d'importance subdural hematomas), drugs (nitrates, chez la personne agee. Les et la cephalee estrogens) and depression, take on greater vasculaire de Horton, meme si elles sont plus significance in the elderly. While and frequentes chez les jeunes adultes, peuvent aussi se cluster are more common in young manifester chez les personnes agees; en effet, les adults, they may begin in older persons; sympt6mes qui accompagnent la cephalee transitoire imitent les attaques d'ischemie cerebrale transitoire. indeed, transient migraine accompaniments Les auteurs esperent que ce resume de la << cephalee are "TIA numimcs". The authors hope that this geriatrique )) facilitera le depistage precoce d'une overview of the "geriatric headache" will condition qui risque souvent de brouiller le facilitate early recognition of this ailment diagnostic. which often leads to diagnostic confusion. (Can Fam Physician 1986; 32:2687-2691.) Keywords: headaches, geriatrics, differential diagnosis

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Dr. Weaver is senior resident in OF THE INNUMERABLE pain ment, the "geriatric headache" has Neurology in the Division of states that afflict humankind, yet to enjoy this special status. Neurology, Department of Medicine headache is the most common. At "Geriatric headaches" frequently at Dalhousie University, Halifax, least 80% of the population suffers share similarities with the headaches Nova Scotia. Dr. Purdy is assistant from headaches, and approximately of young adults, but may also have professor of Medicine in the 20% of the population consults physi- unique characteristics of clinical sig- Division of Neurology, Department cians with headaches as their primary nificance. Headaches may result from of Medicine at Dalhousie complaint. 1, 2 A significant percentage intracranial or extracranial factors, lo- University. Reprint requests to: Dr. of these patients are elderly, and the calized or systemic disease, personal- R.A. Purdy, #2149 Ambulatory causes of their headache problems ity or situational problems, or any Care Centre, Victoria General vary. While "pediatric headache" is combination of these diverse factors, Hospital, Halifax, N.S. B3H 2Y9. recognized as a separate clinical ail- all of which occur with increased fre- CAN. FAM. PHYSICIAN Vol. 32: DECEMBER 1986 2687 quency and under special circum- sify the various types of geriatric Cervical osteoarthritis causes neck stances in the elderly. headache. A classification scheme is pain on motion and can lead to a ten- outlined in Table 1. The headaches sion headache; a similar mechanism Pathophysiology associated with lumbar puncture and exists for cervical disk disease. Of The aging and the post- are usually obvious from equal importance is the psychogenic pericranial structures are particularly the clinical setting and will not be dis- type of , which can sensitive to the various mechanisms cussed. arise in the elderly because of loss of of headache. Between the third and job, loss of financial security, loss of the average male family, or loss of self-esteem. Ten- tenth decades of life Table 1 sion headache frequently accompanies brain loses 233 grams as the neuronal Classification depressive illness. population of the neocortex becomes of Geriatric Headaches progressively depleted.3 Cerebral up- * Muscle-contraction headaches The headache of depression. Head- take of and glucose is re- ache is a common presentation for a duced. Extracranial skeletal muscle -tension -depression depressive illness.7 The recent real- loses cells and undergoes atrophy, -Parkinson's disease ization of a single headache/depres- while collagen undergoes aging -temporomandibular joint syndrome sion ailment has been highlighted by changes that progressively diminish * Vascular headaches the significant analgesic effectiveness its integrity and function. These de- -migraine of antidepressants in the treatment of generative changes, combined with -, and by Sternbach's postu- the generalized regression of other -hemorrhage late that diminished brain serotonin physiological processes, result in an -hypertensive constitutes a common mechanism for enhanced susceptibility to a wide -ischemic * Traction headaches both chronic headache and depres- range of pathological conditions.' sion.8' 9 The headache of depression Moreover, since cancer, , hy- -tumour -intracranial hematoma appears to be of the muscle-contrac- pertension, arthritis and depression * Inflammatory headaches tion type. It is a steady, non-pulsatile, occur with increased frequency in the - pressure-like soreness which fails to elderly, it is not surprising that head- -temporal arteritis respond to standard, effective, pain- ache is a relatively common geriatric -neuralgia relieving drugs. Since depression is complaint. -sinusitis common in the elderly, depression-as- An understanding of geriatric head- * Medication headaches sociated headaches are also common. aches is facilitated by an appreciation - nitrates -analgesic rebound Elderly people make up about 11% of of the relevant pathophysiology. the population, but account for almost Headache may arise from stimulation 20% of suicides.1'( of either extracranial or intracranial structures. The extracranial pain-sen- Muscle-Contraction The headache of Parkinson's disease. sitive structures are the scalp, the ex- Headaches Parkinson's disease is a common tracranial , the mucous mem- These types of headache are the neurological disorder of the elderly. branes of the nasal spaces, the most common, affecting more than Approximately 35% of patients with extemal and middle ears, the teeth, 70% of the population. They probably this disorder complain of headache, and the muscles of the scalp, face and arise from painful contraction of the generally described as a dull, steady neck; the intracranial pain-sensitive extracranial musculature. The pain is ache localized to the nuchal-occipital structures are the venous sinuses, the usually a dull, non-throbbing sore- region."1 Since continuous hypertoni- dura at the base of the skull, the dural ness. city of muscles appears to be one of arteries, the, arteries of the circle of the characteristic neurological signs of Willis, the upper cervical nerves, and Tension headache. Tension headache Parkinson's disease, the headache is the fifth, ninth and tenth cranial is principally a problem of adult life. traditionally classified as a muscle- nerves. The basic mechanisms of It affects women three times as often contraction type. headache involve these pain-sensitive as men.6 A tension headache is structures and include: usually bilateral, often with occipital- Temporomandibular Joint Syndrome * painful contraction of extracranial nuchal or frontal predominance, or Headache. In the elderly, referred muscles; with diffuse extension over the top of head pain from the temporomandibu- * distention or dilation of vascular the cranium. The pain has a tight, lar joint (TMJ) is common, and can structures; squeezing quality, and may be de- arise either from arthritis of the TMJ or * traction caused by direct or indirect scribed as "band-like" or "vice- from denture-associated malocclusion displacement of pain-sensitive struc- like". The headache has a gradual causing muscle imbalance around the tures; onset and continues for long periods TMJ."2 Pathologic etiologies are more * of or near pain-sensi- of time,- sometimes persisting unre- frequent in the elderly. Chewing and tive structures.5 mittingly for weeks, months or even opening the mouth cause discomfort years. Occasionally, there is asso- and may be associated with annoying Clinical Classification ciated "neck soreness" or "scalp ten- "popping" or "clicking" sounds. of Headache Types derness". Tension headaches occur The associated muscle-contraction On the basis of this discussion of with surprising frequency in the older pain is typically unilateral. On exam- pathophysiology, it is possible to clas- age group for a variety of reasons. ination, there 'may be exquisite ten- 2688 CAN. FAM. PHYSICIAN Vol. 32: DECEMBER 1986 derness of the internal pterygoids or spreading transient neurological epi- cally, the headache is severe, but the the masseters. sodes that have a more benign prog- advent of the CT scan has provided ev- nosis than the abrupt onset of TIAS of idence that small intracerebral hemor- occlusive . Despite a rhages may occur in the absence of Vascular Headaches growing body of supportive clinical headache. Vascular headaches occur in 10% evidence, the diagnosis of late-life of the population, and, as with ten- migraine must remain one of exclu- Hypertensive headache. Systemic ar- sion headaches, there is a 3:1 female sion until the limits of this new syn- terial , an extremely com- predominance. These headaches tend drome are better delineated. mon problem in the elderly popula- to be throbbing, paroxysmal and tion, is seldom a cause of headache. hemicranial. Cluster headache. Cluster headache Only at markedly elevated pressures in predominantly affects men and is a which the diastolic pressure exceeds Migraine headaches. Migraine is a relatively unusual disorder occurring 120 mm Hg does the hypertensive common neurological disorder affect- in less than 1% of the general popula- headache occur. Patients with such ing 5% of the general population." tion.1l5 A cluster headache is charac- headaches usually awaken in the The cardinal feature of migraine is a terized by its constant, unilateral orbi- morning with severe, throbbing, occi- paroxysmal throbbing headache, re- tal localization. The pain, which often pital pain that tends to decrease in in- curring at irregular intervals, com- radiates into.the forehead, is deep, in- tensity as the day proceeds. The mech- monly but not invariably unilateral, tense and non-throbbing, and is often anism of the hypertensive headache is usually lasting from two to 20 hours, described as either "searing" or similar to that of migraine, that is, in- and often associated with nausea, "burning". Characteristically, there creased vascular pulsations. vomiting and visual disturbances or is associated ipsilateral lacrimation, Headache of . other disorders of cerebral function. conjuctival injection and rhinorrhea. By far the most common cause of Two important kinds of migraine are The cluster-headache attack has a sud- stroke is or hyperten- recognized: classic and common. den onset, but its duration is brief, sion or both. The incidence of cerebral Classic migraine is a predominantly usually less than 90 minutes. As the infarction is greatest between ages 60 unilateral headache preceded by an name of this disorder implies, the at- and 80, and more than 75% of those aura which most frequently originates tacks tend to recur nightly (or several persons who experience an episode are in occipital cortex, causing an indefi- times during the night and day) for a over the age of 60. Headaches caused nite aberration of vision. Common period of three to eight weeks, fol- by ischemic cerebrovascular disease migraine is a bilateral headache, lo- lowed by complete freedom for many may accompany or even antedate cated behind the eyes. Usually it is months. While cluster headache is symptomatic atherothrombotic disease less severe; usually there is no aura. predominantly a condition of young of the internal carotid and vertebral ar- Migraine is seemingly less preva- adults, with a mean age of onset of teries. Fisher noted headaches in 31% lent in the elderly because about 70% approximately 27-30 years, initial of patients with internal carotid disease of migraineurs are women, and they presentation of this problem in the and in 42% of patients with vertebro- tend to lose their headache suscepti- late sixties is a well-described phe- basilar disease." Likewise, Edmeads bility at menopause. Migraine head- nomenon. ' 6 and Barnett found that 35% of patients aches are thus regarded as an afflic- with internal carotid disease and 51% tion, primarily, of young adults. Headache of intracranial hemor- of patients with vertebrobasilar disease Nevertheless, the newly emerging rhaige. Intracranial hemorrhages of all suffered from headaches.'8 The typi- concept of "late-life migraine accom- types are relatively frequent in the el- cal headache tends to be anterior when paniments" is challenging this view derly. Subdural hematoma is a major the internal carotid is involved, poste- and may make migraine an important cause of headache in this age group. rior when the vertebrobasilar system is diagnostic consideration in the elderly The typical headache is deep-seated, involved, unilateral (ipsilateral to the age group. Fisher has postulated that steady, unilateral or generalized, and diseased vessel), throbbing, worsened some older patients who appear to be is accompanied by drowsiness, confu- by the administration of nitroglycerin, having transient ischemic attacks sion, slurred speech or difficulty in and of variable duration and intensity. (TIA), but who have normal cerebral walking. The precipitating head While the mechanism of these head- angiograms, may, in fact, be suffer- trauma may have been minor and has aches has not been established specifi- ing from migraines, even in the ab- often been forgotten by the patient. In cally, such headaches may indicate an sence of a prior headache history.'4 subarachnoid hemorrhage, the sudden impending ischemic event, and so He asserts that this diagnosis should onset of an explosive, overwhelming, warrant early recognition. be entertained if there is no evidence generalized headache is pathogno- of occlusive vascular disease, embolic monic. The pain is more pronounced Headache of pulmonary disease. Noc- heart disease, or clotting diathesis, posteriorly, and the classic stiff neck turnal vascular headaches occasionally and if several of the following clinical is almost always present. Obtundation occur in elderly patients with chronic features are present during the attacks: of consciousness is usual; nausea and pulmonary disease. Severe noctumal scintillations or visual displays; march vomiting are frequent. In intracerebral oxygen desaturation occurs in these of parathesiae; progression from one hemorrhage, the headache tends to patients, causing cardiac arrhythmias accompaniment to another; associated have variable manifestations, since and electrocardiographic evidence of headache; and the occurrence of two the hematoma may act as a mass le- myocardial . The concomitant or more attacks. In short, Fisher con- sion or may rupture into a ventricle, cerebral hypoxia and hypercapnia tends that these late-life migraines are causing meningeal irritation. Typi- causes headache by a mechanism simi- CAN. FAM. PHYSICIAN Vol. 32: DECEMBER 1986 2689 lar to that of the headache of ischemic usually radiates down the neck and include seeing halos around lights, cerebrovascular disease. into the back. The headache is fre- large pupils and failing vision. Glau- quently agonizing, possessing a can cause severe pain that radi- Traction Headaches "bursting" character. The pain is deep ates intracranially from the eye, with Space-occupying lesions cause seated, constant and associated with accompanying nausea and vomiting. headaches by exerting traction on the stiffness of the neck. It is increased intracranial blood vessels and other with sitting up, shaking the head, or Neuralgia. Neuralgia pain is charac- pain-sensitive structures. These mass any other manoeuvre (such as coughing terized by the paroxysmal onset of lesions include tumour, intracerebral or sneezing) that briefly increases in- sudden, severe, lancinating pain, last- hemorrhage, subdural and epidural he- tracranial pressure. Fever may or may ing one to four minutes and occurring matoma, and . The man- not be present in an elderly patient. several times per day. The pain is typi- ifestations of these headaches are Meningitis occurs more commonly at cally described as shooting, sharp or highly variable. the extremes of age; consequently, it is knife like. The pain has trigger points, a frequent diagnostic consideration in and manipulation of these points pre- The headache ofbrain tumor." A new the elderly. Pneumococcus, staphylo- cipitates the discomfort. Trigeminal onset headache or a change in a coccus, streptococcus and Haemo- neuralgia is a common clinical ailment chronic headache pattern should im- philus inifluenzae are the most common among elderly patients. Postherpetic mediately raise suspicions of intra- microbiological offenders. Meningo- neuralgia occurs most often in the dis- cranial neoplasia. Although headache coccal meningitis tends to be uncom- tribution of the upper division of the is a significant symptom in two-thirds mon after the age of 50. fifth cranial nerve. The pain is burning of patients with brain tumours, many and constant. Infrequently, and in the patients with large supratentorial tu- Temporal alrteritis. 2" This condition is elderly as a rule, the pain becomes mours are entirely headache free. Un- one of the most important causes of chronic and intractable. fortunately, the headache of intracran- headache in the elderly. Temporal ar- ial tumour has no specific features and teritis is a granulomatous inflamma- Sinusitis. Sinusitis is not a common cannot be differentiated clinically from tory disease of medium-sized arteries cause of significant headache in the el- headache attributable to other causes. and occurs at an average annual rate of derly. Acute sinusitis produces a The symptoms can vary from no pain 3 per 100,000 persons. Women are af- throbbing pressure pain over the in- at all to almost any type of headache fected four times as often as men. The volved sinus. Stooping intensifies the pain: focal or diffuse, mild or severe, temporal arteritis headache, although pain, which may be associated with a throbbing or non-throbbing. Nocturnal it takes many forms, usually presents "toothache sensation" if there is max- awakening because of pain, although as a deep, boring, throbbing or non- illary infection, or with "pain in the typical of brain-tumour headache, is throbbing pain which is localized uni- eyes" if the ethmoid labyrinth is in- by no means diagnostic. Activity tends laterally in the affected temple. The fected. The problem recurs and remits to provoke this type of headache, jaw claudication (pain associated with periodically, depending on the drain- whereas rest diminishes it. The pain is talking or chewing) which is seen in age. This characteristic history in asso- usually intermittent, but as the tumour approximately 50% of cases, is a reli- ciation with tenderness over the in- grows, the headaches become more able indicator of temporal arteritis, and volved sinus is a helpful, but not frequent, more prolonged and more se- may even occur without the headache. always adequate, indication for diag- vere, and a host of neurological signs The typical patient often displays con- nosis. When the frontal sinus is in- and symptoms invariably occur. El- comitant constitutional symptoms, in- volved, care must be taken to exclude derly patients tend to have more cancer cluding generalized malaise, weight central nervous system extension. and therefore more metastatic disease loss, myalgias and recurrent fever. Among the elderly, type-B Hemo- of the brain; primary tumours, on the The superficial temporal and other philus influenzae is more common. other hand, do not necessarily become scalp arteries may be thickened and more common with advancing age. tender. The sedimentation rate is Medication Headaches There exists a high incidence of secon- often, but not always, elevated. Tem- The use of multiple medications is dary intracranial extension from lung poral arteritis occurs almost exclu- more common among elderly people and breast cancer; melanoma and hy- sively in the older population and is of than in any other population group. pemephroma, too, are other important particular importance because, if un- Accordingly, the possibility of medi- sources of metastases. Tumours of the treated, it can progress to blindness. It cation-induced headache must always gastrointestinal tract metastasize to should be noted that temporal arteritis be considered. Oral nitrates and vaso- brain less frequently, and generally in- is really a misnomer, since not infre- dilators, used very often in the treat- vade the liver and lung first. quently other arteries, besides the tem- ment of ischemic heart disease, are poral , can be involved. This often headache culprits. Abuse of Inflammatory Headaches condition is actually a systemic vascu- aspirin, acetaminophen or other over- Inflammation of any of the intra- litis with systemic symptoms and the-counter preparations may cause cranial or extracranial pain-sensitive headache. analgesic-rebound headaches. Estro- structures causes headache. It is important to distinguish tem- gens, frequently prescribed for post- poral arteritis from glaucoma. Glau- menopausal women or in the hormonal Meningitis. In meningitis, irritation of coma is another cause of headache manipulation of cancer, are also asso- the meninges by inflammatory exudate which leads to visual problems, and ciated with headache. Since there are causes severe headache. The pain may which is more prevalent in older pa- many other drugs that may be impli- be diffuse or mainly frontal, and tients. Associated signs and symptoms cated in medication-associated head-

2690 CAN. FAM. PHYSICIAN Vol. 32: DECEMBER 1986 aches, polypharmacy in elderly pa- tients with headache must be avoided, A New Standard in Codeine Antitussives for medication may be the cause of TM with chronic headache in some patients. ( PENNKINETIC7 Codeine Effectiveness M GY * PennkineticT Predictability References . 12 Hour therapeu- Steady-state plasma levels of tic blood levels 1. Waters WE.. The Pontypridd headache ticbloodlevels ~ ~-t ~ ~ ~ ~~~j1 everycodeine12-hoursfollowingforPENNTUSS'"5 days, ver- survey. Headache 1974; 14:8 1. * All day, all night sus the traditional formulation c given at 6-hour intervals for 2. Ziegler DK. The epidemiology and gen- co g reie N7 o aays. etics of migraine. Headache 1978; 5:2 1. * Pleasant cherry 3. Adams RD, Victor M. The Neurology flavour o Time(hr) of aging. In: Principles of neurology. 3rd 2 4 6 8 10 12 ed. Toronto: McGraw-Hill, 1985. * Alcohol free; low in calories (6.6 kcal/ PennkineticTm PenntussTm produces 4. Katzman R, Terry RD. The neurology of 5ml) fewer peaks and valleys than conven- aging. Philadelphia: F.A. Davis, 1983. tional medications. * Effective family 5. Lance JW. Mechanismti and manacage- ment of headaiche. 3rd ed. Boston: Butter- medication worth's 1978. N NETI @ _ TM (Controlled release codeine polistirex with 6. Ziegler DK. Tension headache. Med JBlU=J. chlorpheniramine polistirex suspension) Clin North Aim 1978; 62:495. 7. Diamond S. Depression and headache. DOSAGE & ADMINISTRATION SYMPTO TREATMENT OF OVERDOSAGE: Signs ptoms: Serous overdosage with codeine Headache 1983; 23:122. Invert and shake well before using is charcrfzedand by respiratory depression (a decrease in respiraty rate and/or tidal volume, Cheyne-Stokes 8. Lance JW, Curran DA. Treatment of Z2)~) Adults: 2-3 teaspoonsful every 12 respiratIon, ), extreme somnolence progress- chronic tension headache. Lancet 1964; ~ hours; do notexceed 6 teaspoonsful in Ing to stupor or coma, skeletal muscle flaccidity, cold 1:1236. 24 hours. -andclammy skin, and sometimes bradycardia and iX potension. In severe overdosage, apnea, circulatory 9. Sternbach RA, Janowsky DS, Huey LY. Children 6-12: it cpllapse, , and death may occur. The hours; dono in anifestatons of chlorpheniramine overdosage may Effects of brain serotonin on human 24 hou ry from central nervous system depression to chronic pain. In: Bonica JJ, ed. Advances uiiNT Prmary attenton should be given to the in pain research and therapy. Vol. 1. New _, York: Raven Press, 1976. ablishment of adequate respiratory exchange h provision of a patient airway and the institution 10. Drug therapy For depres- Lippmann S. ,~~Ugisted or controlled ventilation. The narcotic antag- sion in the elderly. Postgrad Med 1983; ialoxone hydrochloride (NARCANO) is a specific 73:159. This respiratory depression which may result A ~tt~vrdosage or unusual sensitivity to narcotics 11. Indo T, Naito A, Solve I. Clinical IN : 04-00 ° -g codeine. Therefore, an appropriate dose of characteristics of headache in Parkinson's e hydrochloride should be administered (0.005 - . S; . preferably by the intravenous route, simul- disease. Headache 1983; 23:21 1. y with efforts at respiratory resuscitation. Since 12. Schramm VL. A to t=the4uetion of action of codeine may exceed that of the guide diagnosing ist, the patient should be kept under continued and treating facial pain and headache. or survei,0,illance, and repeated doses of the antagonist Geriatrics August 1980; 78. fluffs,00"000 aVX lf should be administered as needed to maintain adequate '16 C of M0iihi-itorse respiration. (For further information, see NARCAN" full 13. Lance JW, Anthony M. Some clinical Codeine may be . pmnne1 prescribing information). aspects of migraine. Arch Neurol 1966; mycause or aggrveW coNsi An antagonist should not be administered in the 15:356. PregnancyCoPr:{>deine b:: ~absence of clinically significant respiratory or cardio- 14. Fisher CM. Late life migraine accom- placental barnere accordingly,itsin Buse .Inpregancy is vascular depression. Oxygen, intravenous fluids, vaso- notprecommended tnotatio pressors and other supportive measures should be paniments as a cause of unexplained tran- :X:0.nded. employed as indicated. Gastric emptying may be useful CodeineCodeineshouldshouldbe pr*:bedprescribed with caution In chronic in removing unabsorbed drug. sient ischemic attacks. Can J Neurological respiratory pa ment, estihma attack, acute Sciences 1980; 7:9. alcoholsm, or nc t use of CNS depressants. AVAILABIUTY: Red, cherry-flavoured suspension is Use with caution forpents with narrow-angle glau- supplied in 500 ml amber glass bottles. 15. Green MW. Cluster headaches. Post- coma ordifficulty inuiinating due to enlargement of the Each 5 ml contains codeine polistirex equivalent to grad Med 1983; 73:67. prostate gland, except under the advice and supervision 10 mg of codeine, and chlorpheniramine polistirex Of a phyicanequivalent to 4 mg of chlorpheniramine maleate. 16. Kudrow L. Cluster headache: new con- Use wih caution in sedated or debilitated patients, in Codeine is included in the Schedule to the Narcotic cepts. In: Packard RC, ed. Neurologic patnwo have undergone thoracotomies or laparo- Control Act. clinics: headache. Toronto: W.B. tomlws since suppression of the cough reflex may lead Product Monograph available on request. Saunders, 1983. to retention of secretions in these patients. Available by written prescription. Drowsiness may occur; accordingly, ambulatory This product has the potential for being abused. 17. Fisher CM. Headaches in cerebrova- pabents who operate machinery or motor vehicles REFERENCE: *Amsel I.P, Hinsvark ON., Rotenberg scular disease. In: Vinken PJ, ed. Hand- should be cautoned. K, et al: Recent advances in sustained-release book of clinical neurology. Vol. 5. Am- In young children, the respiratory centre is especially technology using ion-exchange polymers. Pharma- susceptible to the depressant acton of narcofic cough ceutical Technology 1984, 8: 28-48. sterdam: North-Holland Publishing, 1986. suppressants. Benefit to risk ratio should be carefully 18. Edmeads J. The headaches of ischae- considered, especially in children with respiratory embarrassment. Estimaton of dosage relative to the mic cerebrovascular disease. Headache and of the child is of great importance. 1979; 19:345. age weight ADVERSE REACTIONS: Codeine may cause consffpa- tiC,,PO 19. Diamond S, Dalessio DJ. Traction and tion, drowsiness, lightheadedness, excitement, nausea Make the inflammatory headache. In: Diamond S, or vomiting. Respiratory depression may occur at IVIIIE9 high doses. D n fi ti TM Dalessio DJ, eds. The practicing physi- The most comnmon adverse reaction of chlorphenira- _ 111, n t e cian's approach to headache. 4th ed. Lon- mine is drowsiness; dry mouth, blurred vision, weak- hn ^ don: Williams and Wilkins, 1986. ness, anorexia, or dysuria may also occur. b|Vb 20. Calamia K, Hunder 6. Clinical mani- festations of giant cell arteritis. Clin Rheum IS P5rIINAILT 1851 Sandstone Manor, Pickering, Ontario LiW 3R9E Dis 1980; 6:389. CAN. FAM. PHYSICIAN Vol. 32: DECEMBER 1986