Patients can be told there is one good thing about getting older - headaches are less frequent. This was recognized in the 1850's when Romberg wrote "hemicrania generally diminishes in advanced age, or entirely ceases; in females it often terminates at the period of decrepitude". Epidemiological studies have confirmed this impression. In 1997 a review of the special problems of diagnosing and treating headaches in the elderly appeared, and it is summarized here.

As in younger age groups, most headaches in the elderly are caused by benign dysfunction - e.g. migraines, tension headaches, cluster headaches. However, these account for only about 2/3 of headaches in the elderly, compared with 90% in younger people. The remaining (nonfunctional) headaches are secondary to systemic diseases or primary intracranial lesions, which are themselves commoner in older persons.

Migraines in the elderly are different from those in younger age groups. They usually decrease in frequency and intensity as people age, but occasionally (about 2%) the first onset is after 50 years of age. In such cases, computerized tomography (CT) or magnetic resonance imaging (MRI) is advisable, to exclude an intracranial lesion. Often, migraine symptomatology changes as the patient ages - auras disappear, or occur without a subsequent headache. As a safety measure, such cases should have CT or MRI investigation.

In treating migraine headaches in the older patient, three points should be remembered: older people do not tolerate medications as well as younger, they may have coexistent conditions that contraindicate certain medications (e.g. coronary artery disease and ergotamine preparations), and some medications may exacerbate migraines (e.g. nitroglycerin, methyldopa).

Diseases causing headaches in the older person include:

• giant cell arteritis (temporal arteritis, Horton's syndrome) - extremely rare, fixed location, increasing intensity over time, diagnosed by biopsy, responds to corticosteroid therapy
• intracranial masses - primary (glioma, meningioma) or secondary (from lung, breast or other neoplasms)
• subdural hematoma - from falls
• ischemic cerebrovascular disease - non-specific, may have warning value
• cervical spondylosis - dull persistent posterior pain
• chronic obstructive pulmonary disease (COPD) - diffuse, dull, throbbing, in the morning

Mention must be made of possible toxic causes. Carbon monoxide exposure causes dull, diffuse headaches, usually in the morning after nighttime buildup in poorly ventilated surroundings. Headaches can be produced by a variety of medications - they are usually dull, diffuse, occasionally throbbing, and non-descript. Common agents are: vasodilators, hypotensives, antiarrhythmic drugs, antiparkinson drugs, sedatives, stimulants, anti-inflammatory drugs, analgesics, H2-blockers, bronchodilators, and some antibiotics.

A condition known as hypnic headaches has been described in people over 65. Bilateral headaches of 30 to 60 minutes' duration wake the patient once or twice a night, almost every night. There is some nausea, but no other symptoms. These headaches respond dramatically to 300-600 mg of lithium taken at bedtime, or indomethacin medication.

Dr Edmeads concludes his review by reminding us that the cause of headache in older persons is more likely to be an underlying disease than is the case in younger people. This makes it important that physicians are willing to investigate carefully all new headaches in the elderly, if necessary with appropriate diagnostic imaging.

Source

• Headaches in older people. How are they different in this age-group? J. Edmeads, Postgrad Med , 1997, vol. 101, pp. 91--100