Headache: Geriatric Headaches
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.
Temporal (giant cell) arteritis (TA) is a systemic panarteritis that
selectively involves arterial walls with significant amounts of elastin.
Approximately 50% of patients with TA have polymyalgia rheumatica, and about
15% of patients with polymyalgia rheumatica have TA. Both conditions occur
almost exclusively in patients older than 50 years, with a mean age of onset of
about 70. The ratio of women to men with TA is 3:1. The annual incidence is
about 18 per 100,000 population in persons older than 50 years.
Headaches are the most common symptom of TA, reported by 60% to 90% of
patients.53 The pain is most often throbbing, although many patients
describe a sharp, dull, burning, or lancinating pain. The pain may be
intermittent or continuous and is more often severe than moderate or slight.
For some patients, the pain may be worse at night when lying on a pillow, while
combing the hair, or when washing the face. Tenderness or decreased pulsation
of the superficial temporal arteries is present on physical examination in
about half of all patients with TA. The location of the headache is variable
and may be unilateral or bilateral. Intermittent jaw claudication occurs in 38%
of cases in which one gets pain associated with talking or eating.
The diagnosis is based on clinical suspicion, which is usually but not
always confirmed by laboratory testing.54 The three best tests are
the Westergren erythrocyte sedimentation rate (ESR), the C-reactive protein
(CRP) level, and temporal artery biopsy. For elderly patients, the ESR range of
normal may vary from less than 20 mm/hr to 40 mm/hr. Elevation of the ESR is
not specific for TA; it can be seen in any infectious, inflammatory, or
rheumatic disease. TA with a normal ESR has been reported in 10% to 36% of
patients. When abnormal, the ESR averages 70 to 80 mm/hr and may reach 120 or
even 130 mm/hr. If the ESR is elevated at the time of diagnosis, it can be
followed to help guide the use of corticosteroid treatment.