Headache in Older Adults: Unique Causes and Treatments

Headache in older adults often represents a different diagnosis than in younger persons, and often with more serious consequences. Although primary headache is common in older adults, headaches secondary to underlying or comorbid conditions become more prevalent with age. The use of multiple chronic medications in the elderly also increases the risk for pharmacy-induced headache.¹

It is important for clinicians to determine potential underlying causes quickly and accurately and to prescribe treatments that take into account comorbidities that older patients may have and medications that they may be taking for them.

Headaches in older adults are less common than in younger persons, but they are still a cause for concern. Although the prevalence of headache decreases after age 40, estimates in people over age 50 range from 12% to 50%, and frequent headaches are reported in up to 17% of people >65 years old, compared with <6% in people <65 years old.^1,2 Risk for secondary headache with potentially life-threatening consequences increases 10-fold in people >65 years.¹

Primary vs Secondary Causes

Older adults are more likely to have primary headache types, most commonly tension-type headache (TTH) or migraine.^1-3 Hypnic headache is a rare primary headache condition seen almost exclusively among older adults.^1-3 At the same time, secondary headaches become more common with age, often related to comorbid conditions and polypharmacy, and these frequently have life-threatening consequences. It is important to rule out secondary causes that are more likely to represent symptoms of an urgent medical condition before diagnosing a primary headache syndrome.

Tension-Type Headache

TTH is the most common type of primary headache in older adults, with a 1-year prevalence of 25% to 35%.¹ The frequency and severity generally declines with age, and so TTH is generally not reported to clinicians as a significant problem. Treatment may require both prophylactic (tricyclic antidepressants) and standard acute pain therapies, which may not be recommended because of increasing polypharmacy and development of comorbidities with age. In particular, tricyclic antidepressants may be contraindicated in individuals with cardiac arrhythmias and may produce excessive anticholinergic effects in older people in general. In addition, nonsteroidal anti-inflammatory drugs often warrant caution in people with gastrointestinal, renal, or cardiac disorders.

Migraine

Migraine is a severe type of headache that usually lasts more than 4 hours and occurs more frequently in women. Although migraine headaches often diminish with increasing age, they still represent the second most common type of headache among older adults, with a 1-year prevalence of approximately 10%.¹

The subtype of migraine is likely to shift with age as well, as a “late in life” migraine that is milder may develop in older adults, or a migraine aura without headache, which is seen more often in people >45 years old.³ Many symptoms — including nausea, vomiting, and sensitivity to light and sound — diminish with age, whereas autonomic symptoms and neck pain tend to increase.¹

Migraine aura without headache may have similar visual, speech, and sensory disturbances seen with transient ischemic attack. Symptoms that develop in a sequential, increasing pattern that abate after 60 minutes or less are more suggestive of migraine aura, which is often followed by a migraine headache in 40% to 50% of cases.⁴ The onset of new symptoms of aura in a patient without a history of migraine requires prompt evaluation for other serious causes, including transient ischemic attack, seizure disorder, and intracranial hemorrhage.³

Hypnic Headache

Hypnic headache is a rare condition that usually occurs only in adults >50 years and most often starts around age 60.^3,5 These are mild to moderate headaches of short duration that rouse an individual while sleeping. The pain is usually dull and not associated with other symptoms of migraine or other headaches. A diagnosis requires a frequency of 15 or more episodes per month; possible secondary causes that should be ruled out include nocturnal hypertension, posterior fossa and pituitary tumors, the use of angiotensin-converting enzyme inhibitors, and in at least one case, sleep apnea.⁵ Hypnic headache is usually very treatable with caffeine, melatonin, or lithium (although this is rarely necessary).¹

Identifying Secondary Causes of New-Onset Headache

A range of underlying causes are known to produce new-onset headache symptoms.^1,3,6 These may be difficult to diagnose, as the headache may be accompanied by multiple other symptoms. Among the most serious conditions are those involving stroke or intracranial hemorrhage or neoplasm. Additionally, headache is often the first sign of giant cell arteritis.

Other conditions that may be infrequently associated with new-onset headache include chronic obstructive lung disease with hypercapnia, cardiac cephalgia, sleep apnea, glaucoma, and cervicogenic headache.

Thunderclap Headache: A Medical Emergency

Thunderclap headache, often described by patients as “the worst headache of my life” involves the sudden onset of sharp headache pain of severe intensity that peaks within 60 seconds.¹ This presentation is indicative of the need for immediate medical evaluation for potential life-threatening conditions such as intracranial bleeding from hemorrhage or hematoma. A blunt trauma to the head from a fall or other event or use of anticoagulant medications should first be ruled out.

In the absence of intracranial bleeding, other serious causes that should be ruled out include reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis, cervical arterial dissection, meningitis, encephalitis, and spontaneous intracranial hypotension.

Giant Cell Arteritis

Giant cell arteritis is a serious multisystem disease that frequently affects the temporal artery or branches of the carotid arteries but may also be present in the aorta and its major branches.^6-8 Giant cell arteritis occurs in individuals >50 years old and the incidence increases with age.

Widespread headache (cranial arteritis) is a frequent first sign. Other symptoms include visual impairment and peripheral neuropathy. The disease may be silent in some patients. Diagnosis can only be confirmed by a positive temporal artery biopsy that shows vasculitis with mononuclear cell inflammatory infiltrates.⁷ Color duplex ultrasonography of the temporal arteries and fluorodeoxyglucose-positron emission tomography with total body contrast-enhanced CT are useful tools for non-invasive diagnosis of giant cell arteritis.⁶

Giant cell arteritis can be treated effectively with glucocorticoids at 40 to 60 mg/day. The addition of 100 mg/day of aspirin has been shown to significantly prevent stroke and vision loss.⁸

References

1. Starling AJ. Diagnosis and management of headache in older adults. Mayo Clin Proc. 2018;93:252-262.
2. Ruiz M, Pedraza MI, de la Cruz C, et al. Headache in the elderly: characteristics in a series of 262 patients. Neurologia. 2014;29:321-326.
3. Bravo TP. Headaches of the elderly. Curr Neurol Neurosci Rep. 2015;15:30.
4. Fisher CM. Late-life migraine accompaniments—further experience. Stroke. 1986;17:1033-1042.
5. Holle D, Naegel S, Obermann M. Hypnic headache. Cephalalgia. 2013;33:1349-1357.
6. Manzo C. Widespread headache as the first clinical manifestation of giant cell arteritis in patients affected by polymyalgia rheumatica. Reumatologia. 2016;54:236-238.
7. Nesher G. The diagnosis and classification of giant cell arteritis. J Autoimmun. 2014;48-49:73-75.
8. Nesher G, Burkun Y, Mates M, Baras M, Rubinow A, Sonnenblick MH. Low‐dose aspirin and prevention of cranial ischemic complications in giant cell arteritis. Arthritis Rheum. 2004;50:1332-1337.