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HEADACHE IN THE ELDERLY*

David J. Capobianco, MD

ABSTRACT
Headaches occur more frequently in the
elderly than is commonly appreciated. This article
discusses the challenges associated with diagnosing and managing headache disorders in the
elderly and reviews the most common primary
headache disorders (late-life migrainous accompaniments, tension-type headache, cluster
headache, and hypnic headache) as well as secondary headache disorders (medication overuse
headache, giant cell arteritis, exploding head
syndrome, and lesional headaches). With a focus
on the different presentations and etiologies of
headache in patients older than 65 years, neurologists have many tools at their disposal for
appropriate management.
(Adv Stud Med. 2003;3(6C):S556-S561)

eadache, migraine in particular, is typically considered a disorder of younger

to middle-aged adults. The prevalence
of migraine is highest between the ages
of 20 and 55 years, peaking at about
age 40 years and declining thereafter.1,2 However, the
primary headache disorders exist in older populations.

*Based on a presentation given by Dr Capobianco at the

American Headache Society Scottsdale Headache
Symposium.
Assistant Professor, Mayo Medical School, Mayo Clinic,
Jacksonville, Florida.
Address correspondence to: David J. Capobianco, MD,
Department of Neurology, Mayo Clinic, 4500 San Pablo Road,
Jacksonville, FL 32224. E-mail: capobianco.david@mayo.edu.

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Prevalence studies report that 53% of men and 64% of

women aged 55 to 74 years experience headache, as well
as 22% of men and 55% of women 75 years and older.3
Headache is reported to be the 10th most common
symptom in elderly women and 14th most common in
elderly men.4 The demographic landscape of headache
etiology changes over time, from predominantly primary
headaches in younger individuals to a greater incidence of
secondary headaches in older individuals, regardless of
sex. Yet, headache remains a significant health problem
for the geriatric population. Consider also that the elderly (ie, those aged 65 years and older) are the fastest growing segment of the US population.5
DIAGNOSIS AND MANAGEMENT CHALLENGES
Obtaining an accurate and detailed history is essential for any headache patient, but even more so with
the elderly patient. A meticulous medication history is
vital, because the potential clue to the headache source
may lie in the medication(s) the patient is taking.
The primary headache disorders, including migraine,
may either attenuate over time (reduced frequency, severity and/or duration) or present in an atypical manner.6
Some patients no longer experience the positive visual
display but may continue to experience the ensuing
headache. Chronic daily headache may continue into
older age. In addition, 5% to 10% of patients older than
65 years first develop chronic daily headache; however,
in the authors experience, many of these patients have a
history of migraine.
Treatment of elderly patients with headaches is far
more challenging than in their younger counterparts
for several reasons, including the increased frequency
of secondary headache, comorbid or coexisting conditions, and polypharmacy. A single diagnosis may no

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longer link the signs and symptoms into a neat, unified headache classification; thus, excluding secondary or symptomatic causes of headache is
absolutely essential. Coexisting diseases complicate
treatment, both acute and preventive. Also, elderly
patients have reduced tolerance to medications due
to changes in hepatic and renal clearance.
Polypharmacy is common; 12% of the population is
older than 65 years, yet they consume more than one
third of all prescription medications.5,6 It is helpful,
therefore, to obtain assistance from the patients primary care physician and/or the pharmacist for a
complete medication history. The advice to start
low and go slow is especially true for the elderly
patient.
Following is a summary of the major primary and
secondary headache disorders in the elderly. The
Figure provides an algorithm for differential diagnosis.

PRIMARY HEADACHE DISORDERS

MIGRAINE AND LATE-LIFE MIGRAINOUS ACCOMPANIMENTS
Although the incidence of migraine peaks in
midlife, approximately one third of migraine patients
continue to experience migraine headaches into older
age. The character of migraine attacks remains the
same: unilateral or bilateral temporal throbbing frequently associated with photophobia, phonophobia,
or nausea, occurring more frequently in women. A
small percentage (2% to 3%) experience their first
migraine after age 50 years.7
Migraine attacks can occur with aura, yet without the
ensuing headache. Late-life migrainous accompaniments, described in Table 1, are an important consideration for the elderly headache patient. The key feature is
the positive visual display, often beginning in one part of
the visual field, then slowly spreading to involve 1 or

Figure. Headache in the ElderlyAn Algorithm for Differential Diagnosis

Adapted with permission from Dodick DW, Capobianco DJ. Headaches. In: Sirven JI, Malamut BL, eds. Clinical Neurology of the Older Adult. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2002.

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both eyes, and generally lasting 10 to 15 minutes.8,9

As the positive visual display abates, the patient may
then experience positive sensory symptoms including tingling or prickling that may begin in the fingertips and spread to the palm or forearm, then
move to the ipsilateral face and tongue, lasting several minutes. As the sensory symptoms resolve in
the affected extremity, the patient may then experience heaviness or clumsiness that lasts several minutes. As the clumsiness abates, difficulty in word
finding may occur.8,9
Late-life migrainous accompaniments are often
stereotypic attacks of short duration, lasting 20 to 30
minutes. The attacks may be identical, suggesting that
the mechanism is not cardioembolic. Patients have
normal neurological exams between attacks.
Approximately one half of the patients may experience
a mild, nonspecific headache.8,9
The key to differentiating late-life migrainous
accompaniments from vascular disease (eg, a transient
ischemic attack) is the serial progression between one
symptom or accompaniment to another. For example,
an acute left middle cerebral artery ischemic infarct
would produce abrupt onset of right hemibody weakness (a negative symptom), right-sided numbness (a
negative symptom), and visual loss (a negative symptom)all occurring simultaneously.7
Late-life migrainous accompaniments represent
a diagnosis of exclusion. Therefore, appropriate
neuroimaging and neurovascular studies, blood
work, and, where appropriate, cardiac studies
should be pursued. Treatment of late-life migrainous accompaniments consists typically of a calcium channel blocker (eg, verapamil). Many
physicians may also add an antiplatelet agent.
Anticonvulsant medications may also be a viable
option for some patients.
TENSION-TYPE HEADACHE
Tension-type headache is more common in elderly than in younger populations, with a reported
prevalence of 27% in patients older than 65 years
compared with 20% in the entire population.10
However, it is difficult to ascertain the true epidemiology of tension-type headache in older persons
because it can be confused with various disorders.
Tension-type headache can be considered a featureless headachedull, bilateral, or diffuse
headache of mild to moderate intensity. There is a

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relative paucity of accompanying migraine features (ie,

nausea, photophobia, phonophobia, worsening with
movement). Tension-type headache can easily be confused with structural or metabolic intracranial disease
or depression, which are both more common in the
elderly population, so careful examination for other
potential causes is imperative.
Tension-type headache, like migraine, in the
elderly should be treated with nonpharmacologic
therapies, with judicious use of abortive and preventive antimigraine medications. Approximately 10%
of individuals will develop tension-type headache
after age 50 years; in these patients, an organic cause
must first be ruled out.
CLUSTER HEADACHE
Cluster headaches, due to the excruciating pain
they inflict, are unmistakable. Sometimes referred to as
suicide headaches, cluster headaches are characterized by intense, severe pain in the orbital region, peaking about 5 minutes after onset, and lasting anywhere
from 15 minutes to 2 hours. Robust autonomic symptoms (eg, lacrimation, nasal congestion, ptosis, meiosis, rhinorrhea, or conjunctival injection) occur in the
vast majority (97%) of patients.7
Cluster headache is uncommon in the elderly but
has been reported in patients as old as 80 years,
accounting for 4% of elderly patients presenting to a

Table 1. Diagnostic Criteria for Late-Life Migrainous

Accompaniments
 Positive visual displays (eg, scintillating scotoma, fortification spectrum)
 Slow or gradual buildup of either visual or sensory symptoms
 Serial progression from one migrainous accompanimentvisual to







sensory to motorwith a delay from one symptom or accompaniment to another

Occurrence of identical attacks
Duration of 20 to 30 minutes
Flurry of attacks in midlife (age 50 to 60 years) is common
Complete resolution between attacks; a benign course without sequelae
Headaches do not follow accompaniments in nearly 50% of cases
Exclusion of symptomatic etiologies

Data from Fisher.8,9

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headache clinic.10 Cluster headache features in the

elderly are stereotypic, but diagnosis warrants imaging
studies to eliminate other possible causes, particularly
with any unusual features at presentation.
Treatment is usually with nasal oxygen, barring any
coexisting medical contraindication. Nasal oxygen is
the safest treatment for those with comorbid cardiovascular disease. Subcutaneous sumatriptan, although
typically very effective, should be avoided, especially in
those with cardiovascular risk factorsa common subpopulation of cluster headache patients. Prophylactic
drug therapy is the same as for younger populations,
excluding methysergide.
HYPNIC HEADACHE
Hypnic headache appears to be a primary
headache disorder distinctly of the geriatric population, with a mean age of onset of approximately 60
years. This rare type of headache, also known as
alarm clock headache, has an estimated prevalence
at the Mayo Clinic of only 0.07%.11 The key feature
of hypnic headache is its nocturnal onset (Table 2).
Hypnic headaches typically begin between 1:00 AM
and 3:00 AM, occurring more than 4 times per week
in two thirds of patients. Hypnic headaches are of
short duration (<2 hours in 64% of cases) with a
lack of associated migrainous and autonomic symptoms that would suggest an alternative primary
headache disorder, such as cluster headache. The
headaches are typically holocephalic and are of moderate severity. Approximately 58% of patients
complain of a dull, nonpulsatile headache, but
42% have some throbbing quality to the pain.
Although initially thought to be more common in
men, as the full spectrum of the hypnic headache
syndrome has evolved, it is apparent that women
are more commonly affected.11-14
Interestingly, resting in a supine position tends
to exacerbate the pain, so many patients may pace
to relieve the pain. Treatment options include
lithium 300 mg daily, indomethacin, or caffeine.
Lithium is often the most effective medication but,
unfortunately, is not well tolerated in geriatric
populations. Caffeine (40 mg to 60 mg) at bedtime can be helpful; our experience has been that
caffeine at bedtime does not interrupt patients
sleep patterns. Several studies have shown that
indomethacin, taken with food at bedtime, is also
useful.14,15

Advanced Studies in Medicine

SECONDARY HEADACHE DISORDERS

MEDICATION OVERUSE
As mentioned earlier, elderly patients consume one
third of all prescription medications. Therefore, the
possibility of medication overuse or rebound headache
should be one of the first considerations in an elderly
patient presenting with headache. As with younger
patients, commonly overused medications by the
elderly for headache include over-the-counter analgesics, combination medications, ergotamine-containing compounds, triptans, and narcotics. It is often
prudent to taper and ultimately discontinue medications that are not absolutely necessary.16
TEMPORAL (GIANT CELL) ARTERITIS
Like hypnic headache, giant cell arteritis (GCA)
appears to be a geriatric headache disorder.6,16-18
Although the temporal artery is frequently involved,
GCA is a systemic granulomatous inflammatory
process (with multinuclear giant cells) affecting medium or large arteries. A necrotizing arteritis is present.
Headache is the most common symptom and the main
reason patients with GCA present to a neurologist. The
prevalence of GCA in patients in their 50s is 6.8 per
100 000; prevalence is 73 per 100 000 in patients in
their 80s.17 The average age of onset is 70 years, and
GCA is 4 times more prevalent in women.17,18
Because the most common symptom is headache,
GCA should be considered in any elderly person with

Table 2. Diagnostic Criteria for Hypnic (Alarm Clock)

Headache
 Occurs only in older or elderly populations (>60 years)
 Headache awakens the patients from sleep at a consistent time, usually between 1:00

AM

and 3:00

AM

(63%)

 Identical headaches also can occur during daytime naps

 Headache frequency often occurring >4 nights/week
 Headache resolution within 2 hours in most patients
 Neurologic examination, laboratory studies, and brain imaging are
unrevealing

 Headache severity remains unchanged or attenuates over time; frequency may vary in either direction
Data from Dodick et al.11

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either new-onset headache or change in a previously

stable headache pattern.17,19,20 There is no specific
headache pattern or characteristic in GCA. In one
study of GCA, the headache occurred outside the temporal region in 25% of cases.20 The headache may wax
and wane in intensity but is usually dull, although
throbbing may occur with bending or stooping. Scalp
tenderness, especially near the temporal or occipital
arteries, is sometimes present.
Polymyalgia rheumatica, malaise, and fatigue occur
in more than one half of GCA patients and may be the
initial symptoms in 20% to 40% of patients.21 Visual
symptoms, including amaurosis, diplopia, and permanent visual loss, are some of the most serious symptoms of GCA. Visual loss can be unilateral or bilateral;
untreated unilateral vision loss can evolve into bilateral visual loss within 1 to 2 weeks. Visual loss is usually
sudden, but Lipton et al have reported gradual visual
loss with recovery after treatment.22 The incidence of
visual loss ranges from 8% to 20%, approaching 40%
in untreated patients.
On examination, the affected artery may be tender
or nodular to palpation.16,18 The best screening test for
GCA is the erythrocyte sedimentation rate; although
admittedly nonspecific, sedimentation rates are elevated in the vast majority of cases. Typical values for GCA
are greater than 50 mm/hour; normal values vary
among laboratories but are typically less than 30
mm/hour.23-25 However, the sedimentation rate may be
falsely low early in the disease course if the patient is
taking corticosteroids or other anti-inflammatory
medications; in patients with sickle cell or low fibrinogen states; and in patients in whom the blood work
was not properly processed (ie, blood was allowed to
sit for more than 2 hours after being drawn).26 Other
laboratory abnormalities may include an anemia of
chronic disease, elevated platelet counts, alkaline phosphatase, C-reactive protein, factor VIII/von
Willebrands factor, fibrinogen, alpha-2-globulin, and
interleukin-6, as expected with vasculitis.27
Temporal artery biopsy may not be technically necessary but prudent; on occasion, one may uncover an
alternative diagnosis.28 Typically, biopsies are performed unilaterally on the side of the tender or
indurated blood vessel. An appropriate segment is 3
cm to 5 cm, multiply sectioned, given that GCA is a
multifocal vasculitis with skip lesions.24,25,27,28
The treatment of choice for this disorder is prednisone (40 mg80 mg starting dose) and should be

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initiated immediately if GCA is suspected.24,25 Patients

taking corticosteroids should be biopsied within 24 to
48 hours of the steroid dose, but a biopsy can be performed up to 2 weeks later. Once improvement is
maintained for 2 weeks, the steroids can be tapered
gradually over weeks to months. Any relapse is usually
due to incomplete suppression of the inflammatory
response, not an exacerbation. As with any long-term
steroid use, patients should be monitored for potential
complications, such as hypertension, osteoporosis,
peptic ulcer disease, diabetes, and cataracts.7,21,25
EXPLODING HEAD SYNDROME
Exploding head syndrome is rare and occurs more
commonly in women than in men. In general, patients
with exploding head syndrome are older than 50 years,
although no age group is spared. It is not a headache per
se, but a cephalic sensation. As patients are falling asleep,
they may awaken with the sensation of a loud noise or a
bang in their head. These sensations may occur several
times per night, and then may remit for several months.
There are no associated autonomic symptoms that
would suggest cluster headache. The mechanism is not
understood but may represent a sleep-related disorder.
Treatment, as suggested by Pearce, who characterized
this syndrome, is reassurance.29,30
LESIONAL HEADACHES
The incidence of lesional headaches increases with
age as the incidence of intracranial disease increases.
The elderly are more prone to the development of subdural hematomas because of the associated cerebral
atrophy that puts the bridging veins at risk of tearing,
even with trivial trauma.
Headaches caused by brain tumor are not easily
identified because the classic cardinal features originally taught in medical school (ie, severe headache, worse
in the morning with associated vomiting) do not hold
true in the majority of patients with a brain tumor. In
fact, many are mistaken for tension-type headache.31
Most are mild and nondescript.7
The majority of patients with brain tumor and associated headache have a history of migraine in their
younger years, underscoring the importance of following
up on any slight change in the quality of headache or
associated features, including slowed mentation. Signs or
clues to brain tumor as the cause of headache include
increased headache frequency, paroxysmal headaches
(with sudden onset and peaking within seconds), and

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associated neurologic signs and symptoms. Magnetic resonance imaging with gadolinium is the imaging method
of choice.
CONCLUSION
Diagnosing and managing headache in the elderly
presents numerous challenges unique to this population. Establishing the correct diagnosis is essential to
implementing the appropriate treatment plan. Any
change in the medication schedule should be reviewed
with the referring primary care physician given the
large number of prescription medications this population consumes.

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