Secondary headaches more common in elderly: diagnosing, managing primary headaches in this population can present challenges, atypical twists

OB/GYN News, April 15, 2005 by Nancy A. Melville

SCOTTSDALE, ARIZ. -- Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at the 2004 Headache Symposium.

The possibility of secondary headache is greater in older patients, and they are more likely than the general population to often experience polypharmacy and drug interactions, said Dr. Swanson, professor of neurology at the Mayo Clinic of Medicine in Rochester, Minn.

Headache prevalence is high in people over the age of 70, ranking as the tenth most common symptom among elderly women. Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).

Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease--both of which are more common in the elderly--as well as medication-induced headaches.

Giant cell arteritis, a necrotizing, granulomatous arteritis that is rarely seen before age 50, also should be considered. "New-onset headache is the key with giant cell arteritis," Dr. Swanson commented.

Other common symptoms of giant cell arteritis include jaw claudication, which occurs in about 40%, and fatigue and fever.

When elderly patients present with a headache, a detailed history should be obtained since co-existing diseases are likely.

"Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects," Dr. Swanson said.

Elderly patients are also prone to have a reduced tolerance to those side effects, he added.

Headaches associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.

The list of drugs that could be etiologic in headaches is extensive, and includes antibiotics such as tetracycline, bronchodilators, cardiovascular drugs such as vasodilators and antihypertensives, sedatives and stimulants, antidepressants such as selective serotonin reuptake inhibitors, and reproductive drugs such as estrogen.

With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists.

Migraine headaches, for instance, peak in prevalence at about age 40 years and are therefore less common in the elderly, making up about 8% of headaches in women over age 60.

In the elderly, migraines can present with reduced severity and frequency than in younger patients.

But there can also be what neurologist C. Miller Fisher, M.D., described as "late-life migraine accompaniments"--including new onset of focal-neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.

Tension-type headaches, although also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.

Treatment of migraine or tension-type headaches in older patients can be difficult. If a prophylactic approach is used, the starting dose should be low and with slow increases, Dr. Swanson said.

Cluster headaches, though also infrequent, are more common among men. "Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography]," he said.

Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups.

First described in 1988 and still rare, it is described as a dull headache that develops only during sleep, yet with "clocklike regularity." The hypnic headache is not attributed to any other disorder; treatments include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted at the meeting.

BY NANCY A. MELVILLE

Contributing Writer