Most primary
headaches in the elderly are similar to those in younger patients (tension,
migraine, and cluster), but there are some differences, such as late-life
migraine accompaniments and hypnic
headaches. Although
migraine in younger persons usually presents with
headache, migraine in older persons may initially appear with visual or sensory phenomena, instead of
headache ("migraine accompaniments"). Hypnic
headaches awaken patients from sleep, are short-lived, and occur only in the elderly. The probability of secondary
headache increases steadily with age. Secondary
headaches include those associated with
temporal arteritis,
trigeminal neuralgia,
sleep apnea, post- herpetic
neuralgia,
cervical spondylosis,
subarachnoid hemorrhage,
intracerebral hemorrhage,
intracranial neoplasm, and
post-concussive syndrome. Certain rescue treatments for
migraine headache in younger individuals (
triptans or
dihydroergotamine, for example) should not be used in elderly patients because of the risk of
coronary artery disease.
Naproxen and
hydroxyzine are commonly used oral rescue
therapies for older adults who have
migraine or
tension headaches. Intravenous
magnesium,
valproic acid, and
metoclopramide are all effective rescue
therapies for severe
headaches in the emergency room setting. Some effective prophylactic agents for
migraine in younger patients (
amitriptyline and
doxepin) are not usually recommended for older individuals because of the risks of
cognitive impairment,
urinary retention, and
cardiac arrhythmia. For these reasons, the recommended oral preventive agents for
migraine in older adults include
divalproex sodium,
topiramate,
metoprolol, and
propranolol. Oral agents that can prevent hypnic
headaches include
caffeine and
lithium.
Cough headaches respond to
indomethacin or
acetazolamide.