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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.

Cerebrovascular Disease

Headaches commonly accompany stroke. In a prospective study of 163 patients with stroke, headache occurred in 29% with bland infarcts, 57% with parenchymal hemorrhage, 36% with TIAs, and 17% with lacunar infarcts.51 Women and patients with a history of prior recurrent throbbing headaches were more likely to have headaches associated with stroke. The headache began before the stroke in 60% of cases and at its onset in 25%. The quality, onset, and duration of stroke-associated headaches vary widely. The headaches are equally likely to be abrupt and to be gradual in onset. In patients presenting with what they consider to be the worst headache of their life, subarachnoid hemorrhage should be excluded.

Headache accompanying stroke is usually unilateral, focal, and of mild to moderate severity, although up to 46% of patients may have an incapacitating headache. The headache may be throbbing or nonthrobbing and, in rare cases, may be stabbing. The headache is more often ipsilateral than contralateral to the side of the cerebral ischemia (reduction in blood supply). Headache is more common in ischemia of the posterior circulation of the brain than of the anterior circulation and more common in cortical (gray matter) than in subcortical events (involving white matter of the brain.) The headache is of longest duration in cardioembolic infarcts and thrombotic infarcts, of medium duration in lacunar infarction, and of shortest duration in TIAs.

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