Unusual Headaches in the Elderly

Diagnosis and management of migraine in ten steps

Migraine is a disabling primary headache disorder that directly affects more than one billion people worldwide. Despite its widespread prevalence, migraine remains under-diagnosed and under-treated. To support clinical decision-making, we convened a European panel of experts to develop a ten-step approach to the diagnosis and management of migraine. Each step was established by expert consensus and supported by a review of current literature, and the Consensus Statement is endorsed by the European Headache Federation and the European Academy of Neurology. In this Consensus Statement, we introduce typical clinical features, diagnostic criteria and differential diagnoses of migraine. We then emphasize the value of patient centricity and patient education to ensure treatment adherence and satisfaction with care provision. Further, we outline best practices for acute and preventive treatment of migraine in various patient populations, including adults, children and adolescents, pregnant and breastfeeding women, and older people. In addition, we provide recommendations for evaluating treatment response and managing treatment failure. Lastly, we discuss the management of complications and comorbidities as well as the importance of planning long-term follow-up.

Headache as an Adverse Reaction to the Use of Medication in the Elderly: A Pharmacovigilance Study

There is a consensus that elderly individuals are quite vulnerable to adverse drug reactions (ADRs), and headaches are one of the most frequent clinical presentations of central nervous system problems in the general population, which can be an ADR. The purpose of our work was to analyze reports of "headache" associated ADRs in the elderly sent to the Portuguese Pharmacovigilance System (PPS), and also which drugs were more frequently associated with this adverse reaction. A retrospective analysis of suspected ADR reports involving patients aged 65 years or older received by the PPS in the last 10 years was conducted. A search of all the terms associated with the High Level Term "headache" was performed. All duplicate reports were excluded from the analysis. A total of 155 ADRs reports were included, in which 15 reported isolated "headache" as suspected ADR, while the remaining 140 ADRs reports reported "headache" together with several other adverse reactions. Most reports of "headache" ADR occurred in women (74.8%; n = 116). About half (46.5%; n = 72) of the ADR reports were considered serious. Anti-viral medication, anti-depressants, anti-dyslipidemic agents and central nervous system-acting analgesics were the most frequent drugs associated with "headache" ADR reports in this population. In elderly patients, most ADR reports involving headaches occurred in women and a high percentage (46.5%) were considered serious. Thus, it is important that healthcare professionals pay more attention to headaches reported as ADRs in the elderly and drugs suspected to cause them, in order to increase knowledge about this type of reaction and contribute towards safely using drugs in this age group.

Diffusion tensor imaging in middle-aged headache sufferers in the general population: a cross-sectional population-based imaging study in the Nord-Trøndelag health study (HUNT-MRI)

BACKGROUND

Several studies have investigated white matter with diffusion tensor imaging (DTI) in those suffering from headache, but so far only in clinic based samples and with conflicting results.

METHODS

In the present study, 1006 individuals (50-66 years) from the general population (Nord-Trøndelag Health Study) participated in an imaging study of the head at 1.5 T (HUNT-MRI). Hundred and ninety-six individuals were excluded because of errors in the data acquisition or brain pathology. Two hundred and forty-six of the remaining participants reported suffering from headache (69 from migraine and 76 from tension-type headache) the year prior to the scanning. DTI data were analysed with Tract-Based Spatial Statistics and automated tractography. Type of headache, frequency of attacks and evolution of headache were investigated for an association with white matter fractional anisotropy (FA), mean diffusivity (MD), axonal diffusivity (AD), radial diffusivity (RD) and tract volume. Correction for various demographical and clinical variables were performed.

RESULTS

Headache sufferers had widespread higher white matter MD, AD and RD compared to headache free individuals (n = 277). The effect sizes were mostly small with the largest seen in those with middle-age onset headache, who also had lower white matter FA. There were no associations between white matter microstructure and attack frequency or type of headache.

CONCLUSION

Middle-age onset headache may be related to a widespread process in the white matter leading to altered microstructure.

Associations of Elderly Onset Headache With Occurrence of Poor Functional Outcome, Cardiovascular Disease, and Cognitive Dysfunction During Long-term Follow-up

Background

Although the frequency and intensity of headaches decrease in older adults, headaches in this population are still an important neurological disorder. The purpose of this study was to investigate the associations of headache characteristics in older adults with the development of cardiovascular disease and cognitive dysfunction.

Methods

We prospectively enrolled 125 older (≥65 years old) patients with headache who were making their first visit to outpatient clinics and who had no prior history of cognitive dysfunction from 11 hospitals in Korea between August 2014 and February 2015. We investigated the occurrence of newly developed/or recurrent headache, cardiovascular disease, cognitive dysfunction, and poor functional outcomes.

Results

The mean age of all included patients was 72.6 years, 68.8% were women, and 43 (34.4%) had newly developed/or recurrent headache during follow-up. During a median follow-up of 31 months (interquartile range, 28–34 months), 21 participants (16.8%) experienced cardiovascular disease, and 26 (20.8%) developed cognitive dysfunction. Upon multivariate analysis and after adjusting for sex, age, and other factors, presence of newly developed/or recurrent headache was found to be associated with cardiovascular disease (hazard ratio [HR], 4.03; 95% confidence interval [CI], 1.28–12.61; p=0.017) and frequency of headache for the recent 3 months was related with cognitive dysfunction (HR, 1.05; 95% CI, 1.00–1.09; p=0.017) and poor functional outcomes (HR, 1.06; 95% CI, 1.01–1.11; p=0.011).

Conclusion

Our study demonstrated that there is an increased risk of cardiovascular disease, cognitive dysfunction, and poor functional outcomes in older patients with frequent, newly developed, or recurrent headache.

New-onset hemodialysis-related headache presenting as migraine aura

Hemodialysis headache (HDH) is an infrequent new-onset symptom, occurring mainly in old uremic patients. Type of pain is nonspecific, occurs during hemodialysis treatment, assuming features similar to tension-type headache and representing a problem, also as regards the therapy to be taken. International Headache Society (IHS) has placed this form of headache among the headaches disorders of homeostasis. We found a case of new-onset HDH in old uremic man, presenting with migraine aura features. A similar case has not been reported in literature, placing us some questions: why and how does this happen? What are the mechanisms involved? Role of trigeminal-vascular system and cortical spreading depression as regards the aura could be considered, through the activation of neuroinflammatory events, lastly causing migraine aura. Moreover, the administration of flunarizine strongly improved migraine symptoms in our patient, as happens in migraine syndromes. Definitely, this case leads us to think that some mechanisms involved in headaches will need to be further clarified.

Characteristics of Elderly-Onset (≥65 years) Headache Diagnosed Using the International Classification of Headache Disorders, Third Edition Beta Version

BACKGROUND AND PURPOSE

New-onset headache in elderly patients is generally suggestive of a high probability of secondary headache, and the subtypes of primary headache diagnoses are still unclear in the elderly. This study investigated the characteristics of headache with an older age at onset (≥65 years) and compared the characteristics between younger and older age groups.

METHODS

We prospectively collected demographic and clinical data of 1,627 patients who first visited 11 tertiary hospitals in Korea due to headache between August 2014 and February 2015. Headache subtype was categorized according to the International Classification of Headache Disorders, Third Edition Beta Version.

RESULTS

In total, 152 patients (9.3%, 106 women and 46 men) experienced headache that began from 65 years of age [elderly-onset group (EOG)], while the remaining 1,475 patients who first experienced headache before the age of 65 years were classified as the younger-age-at-onset group (YOG). Among the primary headache types, tension-type headache (55.6% vs. 28.8%) and other primary headache disorders (OPH, 31.0% vs. 17.3%) were more common in the EOG than in the YOG, while migraine was less frequent (13.5% vs. 52.2%) (p=0.001) in the EOG. Among OPH, primary stabbing headache (87.2%) was more frequent in the EOG than in the YOG (p=0.032). The pain was significantly less severe (p=0.026) and the frequency of medication overuse headache was higher in EOG than in YOG (23.5% vs. 7.6%, p=0.040).

CONCLUSIONS

Tension-type headache and OPH headaches, primarily stabbing headache, were more common in EOG patients than in YOG patients. The pain intensity, distribution of headache diagnoses, and frequency of medication overuse differed according to the age at headache onset.

Headaches of the elderly

The prevalence of headache decreases in elderly age groups; however, headache remains a significant issue with unique diagnostic and therapeutic considerations in this population. While primary headache disorders such as migraine and tension-type headache still occur in the majority of cases, secondary headaches are more common with advancing age. Additionally, several rare primary headache disorders, such as hypnic headache and primary cough headache, occur more frequently in an elderly population and have distinct treatments. In this review, we provide an updated overview of the common, concerning, and unique headache disorders affecting the elderly.

Late-life migraine accompaniments: A narrative review

BACKGROUND

Migraine is one of the most common chronic neurological disorders. In 1980, C. Miller Fisher described late-life migraine accompaniments as transient neurological episodes in older individuals that mimic transient ischemic attacks. There has not been an update on the underlying nature and etiology of late-life migraine accompanimentsd since the original description.

PURPOSE

The purpose of this article is to provide a comprehensive and extensive review of the late-life migraine accompaniments including the epidemiology, clinical characteristics, differential diagnosis, and treatment.

METHODS

Literature searches were performed in MEDLINE®, PubMed, Cochrane Library, and EMBASE databases for publications from 1941 to July 2014. The search terms "Migraine accompaniments," "Late life migraine," "Migraine with aura," "Typical aura without headache," "Migraine equivalents," "Acephalic migraine," "Elderly migraine," and "Transient neurological episodes" were used.

CONCLUSION

Late-life onset of migraine with aura is not rare in clinical practice and can occur without headache, especially in elderly individuals. Visual symptoms are the most common presentation, followed respectively by sensory, aphasic, and motor symptoms. Gradual evolution, the march of transient neurological deficits over several minutes and serial progression from one symptom to another in succession are typical clinical features for late-life migraine accompaniments. Transient neurological disturbances in migraine aura can mimic other serious conditions and can be easily misdiagnosed. Careful clinical correlation and appropriate investigations are essential to exclude secondary causes. Treatments are limited and still inconsistent.

Headache in the elderly: characteristics in a series of 262 patients

INTRODUCTION

Although headache prevalence decreases in patients older than 65, headaches are a common complaint and their different clinical and therapeutic features must be understood. This article analyses the clinical characteristics of elderly patients treated in an outpatient headache unit.

METHODS

We collected demographic and clinical data from patients treated in a tertiary hospital headache unit between January 2008 and May 2013. Headaches were codified according to the International Classification of Headache Disorders, 2nd edition (ICHD-2).

RESULTS

Of a total of 1868 patients treated, 262 patients (14%, 189 women and 73 men) were older than 65 years. Ninety-nine (68 women, 31 men, 5.3% of the total) were over 75. Headaches began after the age of 65 in only 136 patients (51.9%). The 362 headaches were codified as follows: 23.8% as Group 1 (Migraine) and 28.7% as Group 2 (Tension-type headache). We diagnosed 58 (16%) secondary headaches; 26 (7.2%) were classified as Group 13 (Cranial neuralgias) and 23 (6.4%) in Group 14 (Other headaches). Symptomatic medication overuse was detected in 38 patients (14.5%). We also identified headaches considered typical in the elderly, including chronic migraine (41 cases), hypnic headache (6), occipital neuralgia (4), SUNCT (2), cervicogenic headache (1), primary cough headache (1), and giant cell arteritis (2).

CONCLUSIONS

Elderly patients were frequently treated in our outpatient headache unit. Tension-type headache was the most common diagnosis in this population. Geriatric headache syndromes such as hypnic headache or occipital neuralgia were also represented in our series.

Bitemporal scalp, lip and tongue necrosis in giant cell arteritis: a rare presentation

A 74-year-old man was presented with fever, bilateral throbbing temporoparietal headache, jaw claudication, and bilateral loss of vision. On examination, he had bilateral scalp necrosis with impending necrosis of lip and tongue. Temporal artery biopsy was done, and it was compatible with active temporal arteritis. This is one of the rare presentations of giant cell arteritis where there is simultaneous necrosis of scalp, lip, and tongue, and to the best of our knowledge, it is the first case reported from India.