12 Headaches over the Age of 50

The prevalence of headache decreases with older age (Table 12-1) (1). Although 90% of headaches in younger patients are of the primary type, only 66% of those in the elderly are primary (2). There are numerous causes of new-onset headaches in those over 50 years of age (Table 12-2) (3). Although new-onset tension-type headaches are fairly common, migraine and clustertype headaches uncommonly begin after 50 years of age. Temporal arteritis, hypnic headache, and headache of Parkinson’s disease are secondary headaches occurring with much greater frequency in this population. Causes of secondary headache disorders with onset or more common in later life include the following: neoplasms; subdural and epidural hematomas; head trauma; cerebrovascular disease; temporal arteritis; trigeminal neuralgia; postherpetic neuralgia; medication-related headache, including those caused by specific medications and medication rebound; systemic disease, such as infections, acute hypertension, hypoxia, or hypercarbia; and other metabolic disorders, such as hypercalcemia, severe anemia, hyponatremia, and chronic renal failure; diseases of the cranium, neck, eyes, ears, and nose, including cervicogenic headache, glaucoma, otitis, sinusitis, and dental infections; Parkinson’s disease; and angina (also see Chapter 13), which may rarely present with exertional headache without chest pain. In a study of 193 patients 65 years of age and over seen by a neurology service with new-onset headaches, the most frequent diagnoses were tension type (43%) and trigeminal neuralgia (19%) (4). Only one patient met migraine criteria. Fifteen percent had secondary headaches due to conditions such as stroke, temporal arteritis, or intracranial neoplasm. The risk of serious disorders causing headache increased 10 times after age 65, compared with younger patients. This chapter reviews the primary headaches and some of the secondary headaches, including temporal arteritis, postherpetic neuralgia, and Parkinson’s disease. The other secondary headaches are covered in Chapters 6 (medication related), 9 (subdural and epidural hematomas), 14, and 15 (trigeminal neuralgia).