Although it is true that the incidence of migraine, cluster, and tension headache decreases after age 50, headache continues to be a major problem for many people. The vast majority of patients with headaches after age 50 have had pre-existing migraine, tension, or cluster headache, but a significant number of people begin suffering from headache in their 50s and 60s.
When headache begins de novo in adults, a workup is usually indicated, and this is particularly true with advancing age. Intracranial pathology, giant cell arteritis, thrombotic cerebrovascular disease, meningitis, and hypertension
need to to be excluded. In addition, cervical spine disorders may play a role in this age population. Systemic disease, such as chronic renal disease, anemia, and respiratory disorders contribute to headache. The effect of various medications need to be considered as well.
The presence of focal neurologic symptoms requires investigation. A workup is indicated when pre-existing headache patterns change dramatically. It is a very difficult situation in patients with a long history of migraine who have had an MRI scan in the past, and now develop new intracranial pathology.
Cervical spine disease may contribute to headache. However, this is generally overdiagnosed, as cervical radiologic changes are very common after age 50. Headache of cervical origin is usually occipital (back of the head) in location and is often described as a dull ache. However, tension headaches may occur in this location, and it may be difficult to differentiate between the two. Unfortunately, treatment directed at the cervical spine usually leads to less than satisfactory results. Although physical therapy and anti-inflammatories may help, they are often disappointing.
Patients may experience migraine aura without the headache. These aura need to be distinguished from transient ischemic (deficient blood supply) attacks. Depression may exacerbate headache, and the antidepressants often decrease both the headache and the depression. However, the mechanism of action of the antidepressants for headache is usually independent of the antidepressant effect.
The primary headache types after age 50 or 60 are the same as in younger ages; migraine, tension, and cluster. The principles of treatment remain the same; however, in an older population, medication choices are somewhat limited. Anti-inflammatories are used less often because of increased renal and GI toxicity. We use lesser doses with many medications. Ergotamine, with the exception of DHE-45, are generally not employed. Sumatriptan (Imitrex) injections have been valuable in patients under age 65.
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