Headache: Geriatric Headaches
Older persons have fewer headaches than younger ones. The prevalence of headaches at different ages in women and men, respectively, is as follows: 21 to 34 years, 92% and 74%; 55 to 74 years, 66% and 53%; and after age 75, 55% and 22%.46 Although 90% of headaches in younger patients are of the primary type, only 66% of headaches in the elderly are primary.47 There is a decreasing prevalence of migraine with older age. Past the age of 70 years, only 5% of women and 2% of men still have migraine. There are many causes of new-onset headaches in the elderly, some of which can be particularly worrisome.48 The risk of serious secondary disorders in persons older than 65 years is 10 times higher than that in younger persons.49
Late-Life Migraine Accompaniments
Late-life migraine accompaniments are transient visual, sensory, motor, or behavioral neurologic manifestations that are similar or identical to migraine aura.50 Headache is associated with only 50% of cases and may be mild. These accompaniments occur more often in men than in women. From most to least common, migraine accompaniments consist of visual symptoms such as transient blindness, homonymous hemianopsia (loss of vision on one side of one’s visual field), and blurring of vision; paresthesias (numbness, tingling, pins-and-needles sensation), or a heavy feeling of an extremity); brain stem and cerebellar dysfunction such as ataxia (clumsiness), hearing loss, tinnitus (ringing in ears), vertigo (sense of room spinning), and syncope (loss of consciousness); and disturbances of speech, such as dysarthria (slurred speech) or aphasia (loss of ability to speak).
Other causes of transient cerebral ischemia should be considered, especially when the patient is seen after the first episode or if the case has unusual aspects. The usual diagnostic evaluation for transient ischemic attacks (TIAs) or seizures is performed.
Features that help distinguish migraine accompaniments from TIAs include a gradual buildup of sensory symptoms; a march of sensory paresthesias; serial progression from one accompaniment to another; longer duration (90% of TIAs last for less than 15 minutes); and multiple stereotypical episodes.
If the episodes are frequent, preventive treatment can be considered with medications such as verapamil, topirimate, divalproex sodium, aspirin, and clopidogrel. For acute treatment, ergotamine, DHE, and triptans should be avoided because of the risk of increasing blood pressure.