|Year : 2015 | Volume
| Issue : 1 | Page : 15-20
Common primary headaches in geriatrics
Amitava Rudra1, Suman Chatterjee2, Subrata Ray3
1 Department of Anaesthesiology, K.P.C. Medical College, Kolkata, West Bengal, India
2 Department of Anaesthesiology, Midnapore Medical College, Paschim Midnapur, West Bengal, India
3 Department of Consultant Anaesthesiologist, K.P.C. Medical College, Kolkata, West Bengal, India
|Date of Web Publication||1-Dec-2014|
BC-103, Salt Lake, Kolkata - 700 064, West Bengal
Source of Support: None, Conflict of Interest: None
Headaches have become relatively less prevalent in older patients, but still more than fifty percent of people older than 65 years complain about regularly occurring headache. Most of the headaches are primary headaches. Common chronic headache in elderly population include migraine, cluster headache, tension-type headache, and chronic daily headache. The crux of headache management is diagnosis and preventive therapy rather than treating acute attacks. However, diagnostic interventions in geriatric patients do not differ from those in younger headache patients. Although, there is paucity of literature on headache in this special population, we have tried to review the understanding and management of common chronic headache in elderly population.
Keywords: Common, geriatric, primary headaches
|How to cite this article:|
Rudra A, Chatterjee S, Ray S. Common primary headaches in geriatrics. Indian J Pain 2015;29:15-20
| Introduction|| |
Of the innumerable painful states that afflict humankind, headache is the most common and can occur for so many different reasons that its proper evaluation may be difficult. A significant percentage of primary chronic headache patients are geriatric, and the causes of their headache problems vary. Patients with age of 60 years and more are grouped as geriatrics in India.  The geriatric population is around a hundred million in our country, constituting 10% of the total population and the number is steadily increasing.  While "paediatric headache" is recognized as a separate clinical ailment, the "geriatric headache" has yet to enjoy this special status. Improved diagnostic criteria has led to better quality studies and more robust data from clinical trials, and it has engendered a more rigorous approach to headache diagnosis in the clinic, with inevitable improvements in management. Although this has obviously benefited the sufferers of headache, most published data are from younger cohorts, and few clinical trials recruit older people. Moreover, most of the therapy trials even excluded patients above 65 years.  Headache prevalence in the elderly age group ranged from 5% to 50%. ,, Overall, headache appears to be less frequently reported in the elderly population and shows a decline with age.  One of the reasons is that, elderly patients may be less complaining or the emergence of other more serious problems may have suppressed reporting of a benign problem such as headache. Although migraine and tension-type headache appeared to decrease with increasing age, chronic tension headache has significantly prevalence rates in the elderly population.
Most of the headache in elderly population has benign origin, but more care needs to be taken with older patients to rule out underlying pathology, especially when they present for the first time.
This article has been constructed upon a very limited number of studies dealt with headache in geriatric people and limited data on the epidemiology and clinical characteristics of headache in geriatric people.
Headache in the elderly can be divided into primary and secondary types. The most common primary headache types in the geriatrics are migraine, cluster, tension and chronic daily headache.
| Migraine|| |
Migraine is an episodic disorders that is diagnosed from the history. The prevalence of migraine after 65 years was 2.7% for males and 7.6% for females.  Only 5% consult specialists for their headache, therefore clinic-based studies will suffer from referral basis. The available data suggest that older patients with migraine on average have headache on more days. , Migraine can have a devastating impact on the life of a migraine sufferer, personally, financially, and socially, so it is crucial to recognize and treat it appropriately.
Migraine is classified into two main forms, migraine with aura (formerly "classic migraine") and migraine without aura (formerly "common migraine"). Other varieties of migraine include ophthalmogenic, retinal, basilar, and hemiplegic.
Migraines may have complications such as infarction (a neurologic deficit not reversible in 7 days) and status migrainous (an attack of headache or aura lasting more than 72 hours). Persistant aura without infarction occurs when aura symptoms persist for more than 2 weeks without radiographic evidence of infarction.  Migraine and seizures are comorbid disorders.  Headaches are common in the postictal period, but epilepsy can occur triggered by a migraine (migralepsy).
Clinically, there is a shift in the symptomatology with nausea and vomiting and a pulsating character located in the neck.  Amplification of the headache due to physical activity is also reported less often.  Medications seem to influence the attacks better than in younger patients.  However, the common accompanying symptoms of nausea and vomiting may make it difficult for the patient to take oral medication. There is usually photophobia and phonophobia; many patients retire to a dark and quiet room for rest. Constitutional, mood and mental changes are universal, and the patient is usually lethargic for a period after the attack.
Trigger factors may include certain foods, red wine, and hormone replacement treatment in women. Environmental triggers include flickering lights, noise and even certain types of weather changes. Aggravating factors also occur: These include stressors, certain lifestyle habits, and some medications.
Diagnostic problems can be that aura-like phenomenon can also be triggered by cortical ischemia and therefore diagnostic tests should be done with MRI imaging.
Once the diagnosis has been established, reassuring the patient may suffice. Any obvious precipitating cause such as diet, lack of sleep, or environmental factors should be discussed and avoidance of precipitants may prevent attacks. However, in some patients, prophylactic or symptomatic pharmacologic management may be required.
Pharmacotherapy includes treatment of the acute attack and consideration of prophylactic therapy to prevent attacks of migraine or symptomatically to relieve the pain, nausea, and vomiting. Prophylactic therapy is needed when the frequency or duration of attacks seriously interfere with the patient's lifestyle. In general, prophylaxis should be considered if attacks occur as often as 1 to 2 days a week. It should be remembered that changing biology in the elderly will influence response to medication. In general, therefore, pharmacotherapy should be started with caution in the elderly who are often taking medications for other comorbidities. Acute treatment should be started at the onset of an attack with adequate soluble aspirin or soluble paracetamol, often combined with an antiemetic such as domperidone (10 mg). To prevent medication overuse, use of simple analgesics should be limited to 15 days or less per month.
Severe attacks can be treated with one of the 'triptans' (sumatriptan). The 'triptans' (sumatriptan) have revolutionized the life of many patients with migraine and are clearly the most powerful option available to stop a migraine attack. Sumatriptan is a potent vasoconstrictors of the extracranial arteries. These can be administered orally, sublingually, by subcutaneous injection or by nasal spray. The initial dose is 50 mg orally and can be increased to 100 mg if there is no response. Subcutaneous self-administration (4-6 mg once subcutaneously may be repeated once after 2 hours if required, maximum dose 12 mg per 24 hour) is the preferred route when there is significant nausea or vomiting. The advantage is that the drug may be administered at any point during an attack and repeated if necessary. Because sumatriptan may cause coronary vasoconstriction, it is contraindicated in patients with ischemic heart disease or uncontrolled hypertension. Special care is required because loss of subcutaneous fat in elderly may lead to intramuscular injection and more rapid action.
If attacks are frequent and causing disruption of daily life, they can often be prevented with β-blockers, antidepressants, serotonin antagonists and calcium-channel blockers. Treatment is started with a low dose and built to maintenance.
Amongst the β - blockers, atenolol (50 mg to 100 mg daily) has a better side effect profile than propranolol (40 mg to 160 mg daily). Care with β - blockers should be taken when there is presence of peripheral vascular disease.
Amitriptyline (10 mg to 50 mg) is most commonly used antidepressant. Because of side effect (drowsiness, dry mouth, constipation, blurred vision), amitriptyline is administered at the lowest effective dose at bed-time and slowly increased as necessary.
Sodium valproate (300 mg to 600 mg daily) is a well-tolerated drug. Side effects of the drug include tremor, ataxia, and less commonly an extrapyramidal syndrome.
Serotonin antagonist (pizotifen), is a 5-HT 3 antagonist that is usually commenced in a dose of 0.5 mg at night and increased in stepwise manner to a dose of 4.5 mg. It has mild antidepressant activity and also leads to weight gain due to increased appetite.
Tension - type headache
This disease is not the frequently visible type of headache. At the same time it is the least studied type of common headache. 
The second version of the International Classification of Headache Disorders (Headache Classification Subcommittee of the International Headache Society 2004) distinguishes among three forms of tension-type headache (TTH), mainly on the basis of headache frequency.  These are (a) infrequent episodic TTH (less than 12 headache days/year), (b) frequent episodic TTH (between 12 and 180 days/year), and (c) chronic TTH (at least 180 days/year).
Chronic TTH differs not only from the episodic forms in frequency but also with respect to pathophysiology, lack of response to most treatment strategies, more medication overuse, more disability.  The infrequent episodic form has very little impact on the individual and can be regarded as trivial, with no need for medical attention. Patients with frequent episodic or chronic TTH, in contrast, encounter considerable disability and often warrant specific intervention.
The clinical features include
- Pressing/tightening (non-pulsating) quality, with
- Mild or moderate intensity,
- Bilateral location, and
- No aggravation on walking up or down stairs or similar physical activity.
There should not be photophobia and patients should not experience nausea or vomiting. In both types of headache (episodic and chronic), there may be pericranial muscle tenderness. Chronic tension-type headache is more common in the older age groups than episodic tension-type headache. Tension-type headache remains most common in females than in males.
The pain in tension-type headache is usually described as a constant ache, like a tight band about the head or a sensation of wearing a tight cap. In contrast to migraine, the pain may continue for weeks or months without interruption. There may be associated stiffness of the neck and upper back. Scalp tenderness may lead to avoidance of hair combing. The headache may be unilateral or bilateral, commonly occipital or frontal and can be relieved by changing position.
Patients with episodic tension-type headache may experience pericranial muscle tenderness. Depression, anxiety, and other psychological factors are important in the pathogenesis of tension-type headache. The pain is characteristically less severe in the early part of the day and becomes more troublesome as the day goes on. Typically, the headache does not respond well to treatment with analgesics. It may be difficult to differentiate episodic tension-type headache from migraine without aura, particularly when associated symptoms are poorly described or if more than one headache type is present.
- Thorough examination and careful assessment of pain is mandatory. Non-drug management should be considered for all patients with TTH and is widely used. The very fact that the physician takes the problem seriously may have a therapeutic effect, particularly if the patient is concerned about serious disease, e.g. brain tumor and can be reassured. Identification of trigger factors should be performed, since coping with triggers may be of value.
- Physiotherapy (with muscle relaxation and stress management) is usually beneficial.  There is no firm evidence for efficacy of therapeutic touch, cranial electrotherapy, hypnotherapy or transcutaneous electrical nerve stimulation. 
- Paracetamol should be used for acute attacks of pain. Non-steroidal anti-inflammatory drugs (NSAIDs) are more likely to be associated with side effects in the elderly such as gastric erosions, renal and hepatic complications.
- Amitriptyline in low-dose (10 mg at bed time) and titrated by gradual increasing dose weekly or until the patient has either good therapeutic effect or side effects are encountered. It is important that patients are informed that this is an antidepressant agent but has an independent action on pain. 
It is desirable to change to other prophylactic therapy, if the patient does not respond after 4 weeks on maintenance dose. The side effects of amitriptyline include dry mouth, drowsiness, dizziness, constipation, and weight gain.
Note: It is important to bear in mind that secondary headache is more common in the older patient and careful evaluation of the history and examination should be applied in the elderly presenting with apparent non-specific headache.
It is a form of intermittent, short-lived excruciating, unilateral head pain associated with automatic dysfunction. There are several case reports on first manifestation of cluster headache above 65 years of age. ,, Men are more prone to develop cluster headache than women. , The headache is characterized by bouts of severe pain often described as "sharp and boring", but generally not throbbing like migraine. Pain usually reaches its peak intensity in 10-15 minutes and an average of 1 hour. The duration usually ranges from 15 to 180 minutes. The pain is constant, and patient walk around trying to find relief-in contrast to those with migraine who lie quietly. After an attack the patient remains exhausted for some time.  The pain is often centered around one eye; however, it may spread to the whole of the face. The headache may start and end abruptly. The cluster period typically last for 1-2 months and then subsides. Alcohol is a potent precipitant of cluster pain and usually setting off an attack within an hour of ingestion, as are vasodilator drugs such as nitrates.
The cluster headache is divided in two forms, episodic and chronic. The term episodic cluster headache indicates that remissions occur. Attacks occur in periodic cluster pain lasting for 1 month or more. Approximately 85% individuals are affected by episodic cluster headache. However, with chronic cluster headache patients experience daily or near-daily headaches for more than 1 year without remission or remissions that lasts less than a month. Chronic cluster headache occurs in approximately 15% of sufferers.
| Management|| |
The options for preventive management in cluster headache depend on the bout length. Patients with short bouts require medicines that act quickly but will not necessarily be taken for long periods, whereas those with long bouts or indeed those with chronic cluster headache require safe, effective medication that can be taken for long periods.
Verapamil has proven prophylactic efficacy in episodic cluster headache.  The usual dose of verapamil is 80-120 mg 8 hourly.  Verapamil is the drug of choice for all forms of cluster headache prophylaxis. Side effects such as gingival hyperplasia, constipation, and leg swelling are recognized, or cardiac dysrhythmias. Verapamil can cause heart block by slowing conduction in atrioventricular (AV) node. Therefore, a base electrocardiogram (ECG) monitored clinically by the PR interval on the ECG. The dose can be increased depending on the effect and adverse events. Monitoring of ECG and blood pressure should be controlled before each increase in dose. The effects on the AV node take up to 10 days to manifest, 2-week intervals are recommended between dose changes, on the first exposure with ECGs before the next escalation, and routine 6-monthly ECGs after the dose has been established.
Corticosteroids (prednisolone 1 mg/kg, maximum 60 mg daily for a week and reducing by 10 mg a week) may shorten a cluster period but relapse often occurs and so they may be used with other forms of prophylaxis. 
Acute attack management
Cluster headache attacks often peak rapidly and thus require a treatment with quick onset. Oxygen inhalation is useful in the casualty department and can be given at home. This should be given as 100% oxygen at 10 to 12 liters/minute for 15 to 20 minutes. ,, The great advantage of oxygen relies in the absence of adverse events and can be repeated more times during the day.
Sumatriptan 6 mg by subcutaneous injection is effective rapid in onset, and has no evidence of tachyphylaxis. Sumatriptan nasal spray (20 mg per spray) is also effective in acute cluster headache but appears to be less effective. 
Chronic daily headache
Chronic daily headache (CDH) is defined as 15 or more headache days a month for 3 months or more that begins without a history of evaluation from episodic headache. 
The pain is bilateral, pressing, tightening in nature of mild to moderate intensity along with photophobia, phonophobia or nausea. Furthermore, intensity of pain will be aggravated with routine physical activity.
There are several subtypes of CDH with:
- Chronic migraine,
- Chronic tension - type headache,
- Medication overuse headache (analgesics containing caffeine, codeine, barbiturates and tranquilizers),
- Drug-induced headache, and
- Post-traumatic headache.
- Presence of headache more than 15 days/months for at least 3 months.
- Presence of at least two of the pain characteristics:
- Quality of pain should be non-pulsating tightening or pressing.
- Intensity of pain is mild or moderate.
- Pain should be bilateral.
- Routine physical activity should aggravate the intensity of pain.
- Patient will have photophobia/phonophobia or both with absence of moderate or severe nausea.
The management of this syndrome can be particularly challenging and hinges on the discontinuation of analgesic overuse and use of suitable alternatives for weaning and prophylaxis. , Medication withdrawal may be extremely difficult given the psychological and physical dependence on the drug or drugs.  In a proportion of patients the headache may revert to its original episodic form, but in the reminder the avoidance of analgesic overuse will require the initiation of prophylaxis. Suitable prophylactic treatment includes:
- Amitriptyline in an initial dose of 10 mg at night increased to 75 mg as tolerated is effective, with improvement seen at 2-14 days. The drug is best given 12 hours before the patient wishes to wake up to avoid excess morning sleepiness.
- Sodium valproate, starting at 200 mg twice daily and increasing to 400 mg or 600 mg twice daily as tolerated over 2-4-week intervals. The blood count and liver enzymes should be checked at baseline and the various side effects explained to patient.
- Topiramate, starting at 25 mg nightly and increased by 25 mg every 10-14 days to aim for 50 mg twice daily.
- Gabapentine, the dose is 1800-3600 mg daily, it is very well tolerated, although probably less effective from a population view point.
Many medications have been used to treat withdrawal symptoms; however, no evidence based recommendation can be made regarding the most effective withdrawal therapy. 
Note: Patient and physician education is especially important in prevention and management of this difficult headache syndrome.
With increase in the number of geriatric population in the society, morbidity of this age group needs to be understood and treated increasingly.
Headache is one of the most common ailment among geriatric population, although there is paucity of literature about headache in this subset of population, compared to younger population.
While considering pathophysiology, diagnosis, and management of primary headache in geriatric population, one should consider presence of comorbidities and concurrent medication history in detail. Treatment modalities, need to be modified according to changing pharmacodynamics and concurrent drug intake history. Drugs used in prophylaxis and acute treatment may induce unacceptable level of sedation and haemodynamic instability.
In conclusion, primary headache in geriatric population needs more understanding and discussion among medical community.
| References|| |
Das T, Chakraborty S. Geriatrics: The great awakening (editorial). Journal of Indian Medical Association 2014;112:12.
Weaver DF, Purdy RA. The geriatric headache: A unique clinical ailment. Can Fam Physician 1986;32:2687-91.
Saldanha GJ. Headache and Facial Pain. In: Fillit HM, Rockwood K, Woodhouse K, editors. Textbook of Geriatric Medicine and Geriontology. 7 th
ed. Philadelphia: Saunders (Elsevier); 2010. p. 466-77.
Rassmussen BK, Jensen R, Olesen J. A population based analysis of the criteria of the International Headache Society. Cephalalgia 1995;11:129-34.
Prencipe M, Casini AR, Ferretti C, Santini M, Pezzella F, Scaldaferri N, et al
. Prevalence of headache in the elderly population: Attack frequency, disability, and use of medication. J Neurol Neurosurg Psychiatry 2001;70:377-81.
Pfaffenrath V, Fendrich K, Vennemann M, Meisinger C, Ladwig KH, Evers S, et al
. Regional variations in the prevalence of migraine and tension-type headache applying the new IHS criteria: The German DMKG Headache Study. Cephalalgia 2009;29:48-57.
Schwaiger J, Kiechl S, Seppi K, Sawires M, Stockner H, Erlacher T, et al
. Prevalence of primary headaches and cranial neuralgias in men and women aged 55-94 years (Bruneck Study). Cephalalgia 2009;29:179-87.
Bigal ME, Liberman JN, Lipton RB. Age-dependent prevalence and clinical features of migraine. Neurology 2006;67:246-51.
Martins KM, Bordini CA, Bigal ME, Speciali JG. Migraine in elderly: A comparison with migraine in young adults. Headache 2006;46:312-6.
Bento MS, Esperanca P. Migraine with prolonged aura. Headache 2000;40:52-3.
Bigal ME, Lipton RB, Cohen J, Silberstein SD. Epilepsy and migraine. Epilepsy Behav 2003;4 Suppl 2:S13-24.
Wober-Bingol C, Wober C, Karwautz A, Auterith A, Serim M, Zebenholzer K, et al
. Clinical features of migraine: A cross-sectional study in patients aged three to sixty - nine. Cephalalgia 2004;24:12-7.
Wober C, Brannath W, Schmidt K, Kapitan M, Rudel E, Wessely P, et al
; PAMINA Study Group. Prospective analysis of factors related to migraine attacks: The PAMINA study. Cephalalgia 2007;27:304-14.
Kelman L. Migraine changes with age: Impact on migraine classification. Headache 2006;46:1161-71.
Goadsby PJ, Raskin NH. Headache. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Vol. 1. New Delhi, India: McGraw Hill; 2012. p. 112-25.
Garza I, Swanson JW, Cheshire WP, Boes CJ, Capobianco DJ, Vargas BB, et al
. Headache and other Craniofacial Pain. In: Daroff RB, Fenichel GM, Jankovic J, Maziotta JC, editors. Bradley's Neurology in Clinical Practice. 6 th
ed., Vol. 2. Philadelphia: Elsevier (Saunders); 2012. p. 1715-44.
Bendtsen L, Jensen R. Tension-type headache: The most common, but also the most neglected, headache- disorder. Curr Opin Neurol 2006;19:305-9.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2 nd
edition. Cephalalgia 2004;24 Suppl 1:9-160.
Friction J, Vellay A. Ouyang W, Look JO. Does exercise therapy improve headache? A systematic review with meta-analysis. Curr Pain Headache Rep 2009;13:413-9.
Verhagen AP, Domen L, Beger MY, Passchier J, Koes BW. Behavioral treatment of chronic tension - type headache in adults: Are they beneficial? CNS Neurosci Ther 2009;15:183-205.
Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J; EFNS. EFNS guidelines on the treatment of tension - type headache - report of an EFNS task force. Eur J Neurol 2010;17:1318-25.
Fischera M, Anneken K, Evers S. Old age of onset in cluster-headache patients. Headache 2005;45:615.
Straube A, Freilinger T, Ruther T, Padovan C. Two cases of symptomatic cluster - like headache suggest the importance of sympathetic/parasympathetic balance. Cephalalgia 2007; 27:1063-73.
Rigamonti A, Iurlaro S, Zelioli A, Agostani E. Two symptomatic cases of cluster headache associated with internal carotid dissection. Neurol Sci 2007;28 Suppl 2:S229-31.
Dodick DW, Rozen TD, Goadsby PJ, Silberstein SD. Cluster headache. Cephalalgia 2000;20:787-803.
Kudrow L. Diagnosis and treatment of cluster headache. Med Clin North Am 1991;75:579-94.
Goadsby PJ, Lipton RB. A review of paroxysmal hemicrainias, SUNCT syndrome and other short lasting headaches with autonomic features, including new cases. Brain 1997;120: 193-209.
Leone M, D'Amico D, Frediani F, Maschiano F, Grazzi I, Attanosio A, et al
. Verapamil in the prophylaxis of episodic cluster headache: A double-blind study versus placebo. Neurology 2000;54:1382-5.
Francis GJ, Becker WJ, Pringshein TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology 2010;75:463-73.
Leone M, Rapaport A. Preventive management of cluster headache. In: Olesen J, Goadsby PJ, Ramadan NM, Welch KM, editors. The Headaches. 3 rd
ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 809-14.
Cohen AS, Burns B, Goadsby PJ. High - flow oxygen for treatment of cluster headache: A randomized trial. JAMA 2009;302:2451-7.
Fogan L. Treatment of cluster headache. A double-blind comparison of oxygen vs. air inhalation. Arch Neurol 1985;42:362-3.
Van Diet JA, Bahra A, Martin V, Ramadan N, Aurora SK, Mathew NT, et al
. International sumatriptan in cluster headache: Randomized, placebo-controlled, double-blind study. Neurology 2003;60:630-3.
Treatment of acute cluster headache with sumatriptan. The Sumatriptan Cluster Headache study Group. N Engl J Med 1991;325:322-6.
Silberstein SD, Lipton RB. Chronic headache including transformed migraine, chronic tension - type headache, and medication overuse. In: Silberstein SD, Lipton RB, Dalesio DJ, editors. Wolff's headache and other head pain. New York: Oxford University Press; 2001. p. 247-82.
Mathew NT, Kurman R, Perez F. Drug induced refractory headache-clinical features and management. Headache 1990;30:634-8.
Limmroth V, Katsarava Z, Fritsche G, Przywara S, Diener HC. Features of medication overuse headache following overuse of different acute headache drugs. Neurology 2002;59:1011-4.
Calabresi P, Cupini LM. Medication overuse headache: Similarities with drug addiction. Trends Pharmacol Sci 2005;26:62-8.
Rossi P, Jensen R, Nappi G, Allena M; COMOESTAS Consortium. A narrative review on the management of medication overuse headache: The sleep road from experience to evidence. J Headache Pain 2009;10:407-17.