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Expect the Unexpected When
Headache Occurs in Older Patients |
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BY DON SCHRADER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
Headache in older patients presents multiple contrasts in
clinical context that challenge a physician’s usual approach to
workup of headache, said Dr. Robert Kunkel on February 21 at a
headache symposium sponsored by the Diamond Headache Clinical
Research and Education Foundation.
The common headache subtypes—migraine, cluster, and
tension—occur less often in older patients. However, the
definition of “older” differs dramatically from the usual
connotation, substantially increasing the patient population.
“In the field of headache, anyone older than 50 is considered
elderly,” said Dr. Kunkel, consultant at the Cleveland Clinic
Headache and Pain Center. “The reason is that migraine,
tension-type headache, and cluster headache generally start
before age 40.”
Older headache patients have multiple potential causes of
headache rarely seen in younger patients, complicating the
workup. Additionally, sudden onset of headache in an older
patient gives physicians more reason for concern because the
pain can represent a more ominous underlying problem, such as an
aneurysm or arteriovenous malformation.
“Headaches secondary to other diseases, including malignancies,
are much more prevalent in older persons,” said Dr. Kunkel. “Any
headache occurring for the first time in someone over the age of
50, or a change in the pattern of headache in a patient who has
previously suffered with headaches, necessitates a complete
evaluation to look for an underlying cause.”
Migraine rarely has an onset after age 40. In patients who have
a history of migraine, the attacks tend to occur less frequently
and are less severe. Additionally, the typical symptoms, such as
nausea and overall debility lessen with age. Women who have had
a hormonal trigger for migraine will have substantially fewer
attacks after menopause.
On the other hand, migraine variants, such as aura without
headache, occur more often in older patients, said Dr. Kunkel.
Visual symptoms are most common, but aura also presents as
neurologic symptoms. The aura arises and evolves over 15 to 60
minutes, typical of a migraine aura. The visual defects enlarge
and move across the visual field before clearing.
Aura in older patients can present as transient paresthesia,
often unilateral in nature and moving slowly up or down an
extremity.
“Obviously in older patients, neurologic symptoms provide more
reason for concern about cerebral vascular disease, clotting
disorders, and embolic phenomena, all of which must be
excluded,” said Dr. Kunkel.
One clue that paresthesia may represent migraine is the pattern
of resolution. In migraine, the tingling or other neurologic
symptoms clear in the reverse of the order of onset, he added.
Neurologic symptoms resulting from a transient ischemic attack
usually resolve first in the area that was first affected.
Abortive medications frequently used in younger patients become
more problematic in older patients. Many of the drugs are
vasoconstrictive and have to be used with caution in older
patients, who are more likely to have hypertension or cerebral,
coronary, or peripheral vascular disease. The usual prophylactic
drugs work equally well in older and younger patients, although
lower doses should be given to older patients, according to Dr.
Kunkel.
Compared with migraine and cluster headache, tension-type
headache is not so uncommon in older patients, said Dr. Kunkel.
As in younger patients, tension-type headache in older patients
most commonly involves stress and depression. However, many
other explanations have to be considered: cervical arthritis,
poor posture, visual abnormalities, missing teeth, and
ill-fitting or worn dentures.
Physical therapy that includes postural and balance exercises
can be helpful for many older patients with tension-type
headache related to these problems. Preventive medications, such
as tricyclic antidepressants, muscle relaxants, and nonsteroidal
anti-inflammatory drugs, have to be used with caution in older
patients because of a greater potential for adverse effects.
Dr. Kunkel reported that most older patients with a history of
cluster headache can prevent episodes by using typical
preventive medications, such as calcium channel blockers,
lithium, and antiepileptic drugs. Prednisone also offers
effective prophylaxis, but long-term use poses a risk of
osteoporosis and other adverse effects in older patients.
Hypnic headache is one of the few headaches that occur more
often in older individuals. In fact, the nighttime headache
occurs almost exclusively in older people, according to Dr.
Kunkel. The pain presents as a steady discomfort that awakens
the patient from sleep. Usually, the pain is localized to the
frontal area of the head and resolves within 1 to 2 hours. The
condition usually is self-limiting and often resolves after a
few months. Bedtime medication with lithium, a tricyclic
antidepressant, or an antiepileptic drug usually prevents the
attacks.
Temporal arteritis also occurs almost exclusively in people
older than 50. The pain usually arises in the temples and is a
steady, nonthrobbing discomfort. The condition must be
considered in any patient over the age of 50 who presents with
new-onset headache, said Dr. Kunkel.
Temporal arteritis is one of the few headache emergencies, as
the condition poses a risk of permanent vision loss, and stroke
can also occur, although rare. Scalp tenderness is common, and
the temporal artery is often thickened and tender with
diminished or absence pulsation.
“Temporal arteritis is an autoimmune condition that causes
granulomatous inflammation in the medium-sized arteries,” said
Dr. Kunkel. “It is important to recognize and treat this
condition early.”
He explained that the medical causes of headache in older
patients can include hypertension (usually associated with
diastolic blood pressure of 120 mm Hg or higher), sleep apnea,
endocrine abnormalities, malignancy, and infection, either
involving an area of the head or systemic.
Dr. Kunkel added that because older persons take more
medications, headaches associated with medication use are also
more common. Frequently used medications that can lead to
headache include vasodilators, nonsteroidal drugs, histamine-2
blockers, sulfa drugs, tetracyclines, cyclosporine, tamoxifen,
and danazol.
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