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Headache: Geriatric Headaches

Head Trauma

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 Arteritis

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.

WebMD Medical Reference from WebMD Scientific American Medicine

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