Headache: Geriatric Headaches
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.
Although there are numerous causes of head trauma, falls are of particular concern in the elderly. Approximately 30% of all persons older than 65 years fall at least once a year. Subdural hematomas follow approximately 1% of mild head injuries, even those involving no loss of consciousness, such as a bump on the head or riding a roller coaster. Chronic subdural hematomas occur more often in the elderly because of brain atrophy that causes stretching of the parasagittal bridging veins and a predisposition to tearing. The atrophy in an older person also permits hematomas to accumulate without symptoms for a longer period of time than it does in a younger person. Other risk factors include use of aspirin or warfarin52 and alcoholism.
Headaches are present in up to 90% of patients with head trauma. The headaches are nonspecific; they can range from mild to severe and from paroxysmal to constant and can be bilateral or unilateral. They may be exacerbated with coughing, straining, or exercise and may be associated with vomiting or nausea. About 50% of patients with chronic subdural hematomas will have altered mental status. A strokelike presentation with a transient or persistent hemiparesis can also occur. Only about 50% of patients with a chronic subdural hematoma will have a history of a head injury. The history may also be inaccurate in patients with dementia.