Headaches in the elderly

More Attacks and Analgesic Use in Old Age: Self-Reported Headache Across the Lifespan in a German Sample

Background: Reliable population-based data on the prevalence and characteristics of primary headache across the lifespan are essential. However, robust data are lacking.

Methods: We utilized questionnaire data from a random general population sample in Germany, that comprised 2,478 participants aged ≥14 years. A standardized questionnaire addressing headache and headache treatment was filled in during the face-to-face survey.

Results: The 6-month prevalence of self-reported headache in the total sample amounted to 39.0% (known diagnosis of migraine 7.2%; tension-type headache 12.4%; another diagnosis or unknown diagnosis 23.4%). Age-specific prevalence rates were 37.9% (14–34 years), 44.6% (35–54 years), 38.5% (55–74 years), and 26.9% (≥75 years). Compared to age group 14–34, participants aged 35–54 were more (OR = 1.29, 95%-CI 1.05–1.60, p = 0.018) and those aged ≥75 were less (OR = 0.55, 95%-CI 0.40–0.76, p < 0.001) likely to have any headache. Of the participants with headache, 79.5% reported headache on <4 days per month, 15.6% on 4–14 days per month and 4.9% on >14 days per month. The frequency of headache did not differ significantly between age groups in men [χ(3, N = 384)2 = 1.45, p > 0.05], but in women [χ(3, N = 651)2 = 21.57, p < 0.001]: women aged ≥75 years were over-represented in the group reporting 4–14 headache days per month. The analgesic use (days per month) differed significantly between age groups among participants with headache on <4 days per month and on >14 days per month: 1.8 (14–34 years), 2.5 (35–54 years), 3.2 (55–74 years), and 3.4 (≥75 years), respectively 7.9 (14–34 years), 11.4 (35–54 years), 18.4 (55–74 years), and 22.8 (≥75 years).

Conclusions: In general, the prevalence of headache decreases with age. However, older women suffer from more frequent attacks and older participants take analgesics on more days per month than younger participants. This might put them at risk of medication overuse which may lead to medication overuse headache. More research is needed to understand these specifics in headache frequency and treatment behavior in older people.

Characteristics of Migraine in an Out-Patient Population Over 60 Years of Age

One hundred and sixty-three consecutive patients (129 females and 34 males) over 60 years of age attending the Headache Centre of the University of Perugia in the period January 2000-December 2001 were included in the study.

One hundred and fifty-two (93.3%) were affected by a primary headache disorder. According to the 1988 IHS Criteria, their prevailing attacks could be diagnosed as migraine without aura (MwoA) in 57.2% of cases ( n = 87) and as migraine with aura (MwA) in 11.8% of cases ( n = 18). Attacks both in MwoA and MwA were unilateral and of severe-to-moderate intensity in 45% and 50% of cases. Head pain was referred as pulsating by 56% and 38.9% of MwoA patients MwA patients, respectively. Aggravation with routine daily activities was present in 72.4% and 61.1% in MwoA and MwA patient groups. The most frequent accompanying symptoms were photophobia and phonophobia. Headache attacks were of shorter duration in MwA patients, but in 3.4% of MwoA patients attacks lasted between 2 and 4 h. Of patients affected by MwA, 55% referred, together with the typical attacks, symptoms of aura not followed by headache. A worsening of headache in the last 5 years was reported by 67.8% and 44.4% of MwoA and MwA patients, respectively. Of the patients with MwoA, 86.2% ( n = 75), and 83.3% ( n = 15) of those with MwA used symptomatic drugs for their attacks. In the majority of cases they took more than one analgesic or non steroidal anti-inflammatory drug. A total of 51.7% of patients with MwoA and 55.5% of patients with MwA were under prophylactic treatment. Preventive drugs included antidepressants, beta-blockers, calcium channel antagonists and antiepileptic drugs. The choice of symptomatic or prophylactic drugs was made, in the majority of cases, on the basis of concomitant diseases.

Migraine in The Elderly: A Review

Although migraine is less prevalent in older than in younger age groups, the absolute increase in the number of subjects in older age groups may lead to an increase in the total number of migraine patients. Consequently, more elderly migraine patients may seek medical attention. In this review, the epidemiology and clinical aspects of migraine in the age group of ≥60 years are summarized, with special attention to comorbidity. The review will focus on treatment choices in elderly migraine patients. These must be based on knowledge of mechanisms of physiological and pathological ageing.

Lower Sodium Intake and Risk of Headaches: Results From the Trial of Nonpharmacologic Interventions in the Elderly

OBJECTIVES

To determine the effect of sodium (Na) reduction on occurrence of headaches.

METHODS

In the Trial of Nonpharmacologic Interventions in the Elderly, 975 men and woman (aged 60-80 years) with hypertension were randomized to a Na-reduction intervention or control group and were followed for up to 36 months. The study was conducted between 1992 and 1995 at 4 clinical centers (Johns Hopkins University, Wake Forest University School of Medicine, Robert Wood Johnson Medical School, and the University of Tennessee).

RESULTS

Mean difference in Na excretion between the Na-reduction intervention and control group was significant at each follow-up visit (P < .001) with an average difference of 38.8 millimoles per 24 hours. The occurrence of headaches was significantly lower in the Na-reduction intervention group (10.5%) compared with control (14.3%) with a hazard ratio of 0.59 (95% confidence interval = 0.40, 0.88; P = .009). The risk of headaches was significantly associated with average level of Na excretion during follow-up, independent of most recent blood pressure. The relationship appeared to be nonlinear with a spline relationship and a knot at 150 millimoles per 24 hours.

CONCLUSIONS

Reduced sodium intake, currently recommended for blood pressure control, may also reduce the occurrence of headaches in older persons with hypertension.

Cultural adaptation and reproducibility validation of the Brazilian Portuguese version of the Pain Assessment in Advanced Dementia (PAINAD-Brazil) scale in non-verbal adult patients

Objective

To adapt the Pain Assessment in Advanced Dementia (PAINAD) scale to Brazilian Portuguese with respect to semantic equivalence and cultural aspects, and to evaluate the respective psychometric properties (validity, feasibility, clinical utility and inter-rater agreement).

Methods

Two-stage descriptive, cross-sectional retrospective study involving cultural and semantic validation of the Brazilian Portuguese version of the scale, and investigation of its psychometric properties (validity, reliability and clinical utility). The sample consisted of 63 inpatients presenting with neurological deficits and unable to self-report pain.

Results

Semantic and cultural validation of the PAINAD scale was easily achieved. The scale indicators most commonly used by nurses to assess pain were “Facial expression”, “Body language” and “Consolability”. The Brazilian Portuguese version of the scale has proved to be valid and accurate; good levels of inter-rater agreement assured reproducibility.

Conclusion

The scale has proved to be useful in daily routine care of hospitalized adult and elderly patients in a variety of clinical settings. Short application time, ease of use, clear instructions and the simplicity of training required for application were emphasized. However, interpretation of facial expression and consolability should be given special attention during pain assessment training.

The prevalence of headache and associated psychosocial factors in an urban biracial sample of older adults

OBJECTIVE

There are limited epidemiological data about headache in urban elderly persons in the United States, especially those from minority backgrounds. This article examines the prevalence of headache and associated psychosocial factors in a biracial sample of older adults in New York City.

METHODS

Data from a population-based sample consisting of 214 Caucasians and 859 Blacks aged 55 and over (mean age: 68 years) were analyzed using an adaptation of George's Social Antecedent Model of Psychopathology. The model consisted of 15 independent variables, one interactive variable, and a dependent variable that dichotomized headaches that bothered respondents into "none or little of the time" versus "some, a good part, or most of the time" in the past few weeks.

RESULTS

Controlling for design effects, 17.8% of the sample met headache criteria. For the entire sample, logistic regression analysis indicated that headache was significantly associated with anxiety symptoms, depressive symptoms, religiosity, and a smaller proportion of confidantes. When examined separately, headache among blacks was significantly associated with anxiety symptoms, larger social networks, and greater financial strain. Among Caucasians, headache was associated with anxiety symptoms, smaller social networks, religiosity, physical illness, and higher daily functioning.

CONCLUSIONS

The study confirms earlier findings that anxiety and depressive symptoms are associated with headache in older adults. The results also identify other psychosocial factors that may differ by race. These findings have important implications with respect to the etiology and management of headache in older adults.

Secondary headaches in the elderly

The prevalence of headache decreases with age. However, headache is still ranked as one of the most frequent complaints in the elderly. Aging is accompanied by a decline in the incidence of most primary headache disorders and by an increase in organic causes of headache, especially after 55-60 years of age. New onset headaches or a change in headache pattern in this age group carries a high index of suspicion for organic diseases. A broad differential diagnosis and unique diagnostic considerations must be considered. Secondary headache disorders reflect underlying organic diseases such as giant cell arteritis, intracranial mass lesion, cerebrovascular diseases or metabolic abnormality.

Coping with chronic pain among younger, middle-aged, and older adults living with neurological injury and disease

Objective. This article compares use of pain coping strategies among older, middle-aged, and younger adults living with chronic pain and seeks to determine whether the relationship between pain severity and coping is moderated by age. Method. Participants were 464 adults reporting chronic pain secondary to multiple sclerosis, spinal cord injury, or neuromuscular disease. Participants completed a survey including measures of pain severity and the Chronic Pain Coping Inventory. Results. After controlling for clinical and demographic variables, older adults (older than 60) reported a wider range of frequently used strategies and significantly more frequent engagement in activity pacing, seeking social support, and use of coping self-statements than did younger or middle-aged adults. Moderation analyses suggest that, for younger adults, efforts at coping generally increased with greater pain severity, whereas this relationship did not exist for older adults. Discussion. These data suggest differences in the quantity and quality of pain coping among age groups.

Practical considerations for the treatment of elderly patients with migraine

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.

Headache Disorders in the Elderly

Headache prevalence declines in the elderly, but remains a common reason for patients to seek medical attention. Although primary headache types remain most frequent, secondary headaches become more likely in this age group. Accurate diagnosis is essential, and the clinician should maintain a lower threshold for ordering laboratory testing and neuroimaging. The elderly are more likely to have co-existent medical conditions, which present both therapeutic limitations and opportunities when selecting acute and preventative treatments for headache. Altered pharmacokinetics and pharmacodynamics in this age group may increase the likelihood of side effects and drug interactions. Downward dose adjustments and simplifying medication regimens are often appropriate, as is using nonpharmacologic therapies whenever possible. Due to frequent contraindications related to acute medications, preventative drug regimens and nonpharmacologic treatments assume greater prominence when treating the elderly suffering frequent/severe headaches. Medication-induced headache and analgesic rebound headache occur commonly in this age group and may initiate, aggravate, or perpetuate headache. Chronic daily headache is often due to these conditions, and recognition of these problems can allow effective intervention.

Diagnostic testing for headache

A careful and complete headache history supplemented by a neurologic and general physical examination, as appropriate, enables the astute physician to diagnose most headaches correctly without diagnostic testing. When indications are present (see Box 1), some headache patients with a normal physical examination require testing even though the yield may be low. Failure to test may result in misdiagnosis of potentially serious and life-threatening causes of headaches, such as brain tumors, chronic meningitis, SAH, and temporal arteritis.

Functional abdominal pain in the elderly

Although aging per se affects function throughout the gut, particularly after age 70, the observed changes are relatively modest and often asymptomatic, perhaps because of the vast reserve of neuromuscular functional elements in the gut. The proximal esophagus, anus, and pelvic floor are possible exceptions to this generalization, and the combination of aging and factors such as minor strokes or obstetric damage often results in dysphagia, constipation, or fecal incontinence. Managing elderly patients with functional abdominal pain demands clinical acumen, tact, understanding, and patience. Further studies are required to elucidate the consequences of aging on gastrointestinal sensorimotor function at several levels of the digestive tract. With the expected explosion in the proportion of the population older than age 75, this field should become a high priority for clinical and research efforts. Also required will be a major campaign to educate patients and practitioners and multidisciplinary collaborations among primary care practitioners, gastroenterologists, psychologists, and physiatrists to provide optimal pain management in the elderly.

Cranial arteritis: a medical emergency with orofacial manifestations

BACKGROUND

Cranial arteritis, or CA, a vascular disease affecting primarily elderly people, may result in permanent blindness if untreated. Since it frequently mimics temporomandibular joint, myofascial or odontogenic pain, dentists must be familiar with this condition.

CASE DESCRIPTION

The authors present reports of two patients who had signs and symptoms of CA, some of which were suggestive of other head and neck pain disorders. In both cases, the diagnosis of CA was confirmed by temporal artery biopsy, and treatment with systemic steroids resulted in rapid resolution of symptoms.

CLINICAL IMPLICATIONS

Prompt diagnosis and treatment of CA not only results in resolution of symptoms, but also may prevent blindness, the most serious sequela of the condition.

Migrainous visual accompaniments are not rare in late life: the Framingham Study

BACKGROUND AND PURPOSE

Questionnaires to elicit symptoms of transient ischemic attacks (TIAs) may detect late-life transient visual symptoms similar to the visual aura of migraine, often without headache. We determined the frequency, characteristics, and stroke outcome of these symptoms in the Framingham Study.

METHODS

During 1971-1989, at biennial examinations, 2110 subjects of the Framingham cohort were systematically queried about the occurrence of sudden visual symptoms.

RESULTS

Visual migrainous symptoms were reported by 1.23% (26/2110) of subjects (1.33% of women and 1.08% of men). In 65% of subjects the episodes were stereotyped, and they began after age 50 years in 77%. Mean +/- SD age at onset of the episodes was 56.2+/-18.7 years. In 58% of subjects the episodes were never accompanied by headaches, and 42% had no headache history. The number of episodes ranged from 1 to 500 and was 10 or more in 69% of subjects. The episodes lasted 15 to 60 minutes in 50% of subjects. Sixty-five percent of the subjects were examined by a study neurologist, and only 19% of them met the criteria of the International Headache Society. Twelve percent of subjects sustained a stroke after the onset of migrainous visual symptoms: a subarachnoid hemorrhage 1 year later, an atherothrombotic brain stem infarct 3 years later, and a cardioembolic stroke 27 years later. In contrast, of 87 subjects with TIAs in the same cohort, 33% developed a stroke (P = 0.030), two thirds within 6 months of TIA onset.

CONCLUSIONS

Late-life-onset transient visual phenomena similar to the visual aura of migraine are not rare and often occur in the absence of headache. These symptoms appear not to be associated with an increased risk of stroke, and invasive diagnostic procedures or therapeutic measures are generally not indicated.

Emergency department evaluation of headache

Headache is an extremely common complaint in the Emergency Department, accounting for up to 16% of all visits. Although there are more than 300 medical conditions which can produce headache, the vast majority of headache disorders are benign. This article outlines an orderly approach for evaluating patients who present with headaches; in addition, the authors discuss the emergency treatment of the more common types of headache.

Diagnostic testing for the evaluation of headaches

Headaches are one of the most common symptoms that neurologists evaluate. Although most are caused by primary disorders, the list differential diagnoses is one of the longest in all of medicine, with over 300 different types and causes. The cause or type of most headaches can be determined by a careful history supplemented by a general and neurologic examination. Reasons for obtaining neuroimaging include medical indications as well as anxiety of patients and families and medico-legal concerns. In the era of managed care, concerns over deselection and negative capitation may dissuade the physician from ordering even a medically indicated scan. The yield of neuroimaging in the evaluation of patients with headache and a normal neurologic examination is quite low. Combining the results of multiple studies performed since 1977 for a total of 3026 scans reveals the overall percentages of various pathologies as: brain tumors, 0.8%; arteriovenous malformations, 0.2%; hydrocephalus, 0.3%; aneurysm, 0.1%; subdural hematoma, 0.2%; and strokes, including chronic ischemic processes, 1.2%. EEG is not useful in the routine evaluation of patients with headache. Similarly, the yield of neuroimaging in the evaluation of migraine is quite low. Combining the results of multiple studies performed since 1976 for a total of 1440 scans of patients with various types of migraine, the overall percentages of various pathologies are: brain tumor, 0.3%; arteriovenous malformation, 0.07%; and saccular aneurysm, 0.07%. WMA have been reported on MRI studies of patients with all types of migraine, with a range from 12% to 46%. The cause of WMA in migraine is not certain. Cerebral atrophy has been variable reported as more frequent and no more frequent in migraineurs compared with controls. The "first or worst" headache has a long list of possible causes and always includes the possibility of acute subarachnoid hemorrhage. Headaches--especially the sentinel type caused by SAH--often are misdiagnosed. The probability of detecting an aneurysmal hemorrhage of CT scans performed at various intervals after the ictus is: day 0.95%; day 3, 74%; 1 week, 50%; 2 weeks, 30%; and 3 weeks, almost nil. The location of a ruptured saccular aneurysm often is suggested by the predominant site of the SAH. The probability of detecting xanthochromia with spectrophotometry in the CSF at various times after a subarachnoid hemorrhage is: 12 hours, 100%; 1 week, 100%; 2 weeks, 100%; 3 weeks, more than 70%; and 4 weeks, more than 40%. The management of thunderclap headaches with normal CT scan and CSF examinations is controversial. Most patients have a benign course but an unruptured saccular aneurysm occasionally may be responsible for the headache. MR angiography may be a reasonable test to obtain instead of a cerebral arteriogram in many of these cases. About 30% to 90% of patients have headaches of various types and causes after mild head injury. Although most headaches are relatively benign, perhaps 1% to 3% of these patients have life-threatening pathology, including subdural and epidural hematomas, that are detected on CT and MRI scans. Headaches caused by subdural hematomas can be nonspecific. When new-onset headaches begin in patients over the age of 50 years, the physician always should consider whether it may be a secondary headache disorder requiring specific diagnostic testing and treatment. Up to 15% of patients 65 years and over who present to neurologists with new-onset headaches may have serious pathology such as stroke, TA, neoplasm, and subdural hematoma. Headaches are the most common symptom of TA, reported by 60% to 90%. The only over the temple. The diagnosis of TA is based on a high index of clinical suspicion that usually but not always is confirmed by laboratory testing. The erythrocyte sedimentation rate can be normal in 10% to 36% of patients with TA. A superficial temporal artery biopsy can give a false-negative result in 5% to 44% of patients.