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Headache: Geriatric Headaches

Postherpetic Neuralgia

Although herpes zoster most commonly occurs in the thoracic region, the second most commonly involved area is a trigeminal distribution, usually in the ophthalmic division (herpes zoster ophthalmicus), which occurs in 23% of cases. The zoster is almost always unilateral. The incidence of postherpetic neuralgia (PHN) (i.e., the persistence of pain for more than 1 month after the initial outbreak) greatly increases with older age, to about 1,000 per 100,000 population for those 80 years of age or older. PHN develops in 50% of persons older than 50 years and in 80% of those older than 80 years. Zoster involving the face nearly doubles the risk of developing facial PHN, which lasts longer than PHN in other locations.

Typically, the vesicles crust, the skin heals, and the pain resolves within 3 to 4 weeks after the onset of the rash of herpes zoster. PHN involves three types of pain: a constant burning or deep aching; an intermittent spontaneous pain with a jabbing or lancinating quality; and a superficial, sharp, or radiating pain or itching provoked by light touch (allodynia), which is present in 90% of persons with PHN and often interferes with sleep.56 The type of pain experienced varies from patient to patient.

Oral corticosteroids (e.g., prednisone, starting at 60 mg/day and tapering off over 2 weeks) may reduce acute pain in herpes zoster but do not lower the risk of PHN. One week of therapy with famciclovir (500 mg every 8 hours) or valacyclovir (1,000 mg every 8 hours), ideally started within 72 hours after onset of acute zoster, mildly reduces the risk and duration of PHN.57 Numerous treatments of varying efficacy are available for PHN, including tricyclic antidepressants (amitriptyline, nortriptyline, and desipramine), gabapentin, topical agents (capsaicin, lidocaine, aspirin, and NSAIDs), opioids, and tramadol. Unfortunately, PHN persists for 1 year or more in over 20% of patients.

Cardiac Ischemia

In rare cases, cardiac ischemia can cause a unilateral or bilateral headache brought on by exercise and relieved by rest.58 The headache can occur alone or can be accompanied by chest pain. Angina is generally believed to be caused by afferent impulses that traverse cervicothoracic sympathetic ganglia, enter the spinal cord via the first to the fifth thoracic dorsal roots, and produce the characteristic pain in the chest or inner aspects of the arms. Cardiac vagal afferents, which mediate anginal pain in a minority of patients, join the tractus solitarius. A potential pathway for referral of cardiac pain to the head would be convergence with craniovascular afferents.59

Hypnic Headache

Hypnic headache is a rare disorder that occurs in men and women from 40 to 79 years of age.60 The headache occurs only during sleep and awakens the sufferer at a consistent time. Nausea is infrequent, and autonomic symptoms are rare. The headache can be unilateral or bilateral, throbbing or nonthrobbing, and mild to severe in intensity. The headaches can last 15 minutes to 6 hours and can occur frequently, as often as nightly, for many years. Medications reported to be effective include caffeine (one or two cups of caffeinated coffee or a 40 to 60 mg caffeine tablet before bedtime), lithium carbonate (300 mg at bedtime), indomethacin, atenolol, melatonin, cyclobenzaprine, prednisone, and flunarizine (not available in the United States).

The diagnosis is one of exclusion. Secondary causes of nocturnal headaches that must be ruled out include drug withdrawal, temporal arteritis, sleep apnea, oxygen desaturation, pheochromocytoma, primary and secondary neoplasms, communicating hydrocephalus, subdural hematoma, and vascular lesions.61 Migraine, cluster, and chronic paroxysmal hemicrania are other primary headaches that can cause awakening from sleep. Migraine typically has associated symptoms and very uncommonly occurs only during sleep. Cluster headaches have autonomic symptoms and may occur during the day as well as during sleep. Chronic paroxysmal hemicrania occurs both during the day and at night, lasts for less than 30 minutes, and occurs 10 to 30 times a day.

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WebMD Medical Reference from WebMD Scientific American Medicine

Reviewed by Lily Jung, MD on December 01, 2006

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