Table 1. Prevalence and treatment of primary headache syndromes in the elderly (> 55 years old).
| Headache syndrome | Prevalence | Change in clinical presentation | Treatment | Caveat Always: more drug-drug interactions and side effects |
|
|---|---|---|---|---|---|
| Attack | Prophylaxis | ||||
| Migraine | 1-year: 6%-20% Life-time: 20%-34% |
Headache severity decreases. Aura persists. Attacks more often in nights and mornings | Tailor-made. Consider non-pharmacologic treatment | Comorbid depression and cerebrovascular conditions | |
| Simple analgesics Triptans |
Start low, increase slowly |
||||
| Tension type headache | Episodic: 25% Chronic: 1%-3% |
Similar to younger patients. Pressing, band feeling, no clear accompanying symptoms | Maximum 2 days/ week Simple analgesics +/- caffeine | Amitriptyline | 20%-50% of TTH phenotype is secondary |
| Trigeminal autonomous cephalalgias | Rare | Relatively more often women. Little/no accompanying symptom | Oxygen Triptans | Avoiding alcohol in bout Verapamil; lithium; anti-epileptics |
Pseudo dementia as presentation of agitation/urge to move |
| Medication-induced/overuse headache | 15% | Related to drugs: as side effect / analgesics overuse | Education; withdraw all analgesics and caffeine/thein-containing drugs/ foods/ beverages. Afterwards: treat underlying primary headache syndrome | Frequent use of drugs with headache as side effects, or analgesics overuse | |
| Hypnic headache | 0.07%-0.35% of headache Almost all patients >50 years | Nocturnal attacks, 15-40 minutes, no accompanying symptoms ‘Alarm clock headache’ | Not always necessary: shortlasting and mostly self-limiting. Option: caffeine +/– simple analgesics; triptans | Caffeine Lithium Indomethacin | Sleep apnea Nocturnal hypertension Comorbid migraine and TTH |
| Exploding head syndrome | N = 112 cases; all > 50 years | Male / female= 1 : 1.55 Attacks with perception of sound, fear and sometimes headache. During sleep (30%), or sleep/wake transition (65%). | Information; reassurance | TCAs; anti-epileptic drugs; calcium channel blockers (all without evidence) Treatment of comorbid sleep apnea | Considered a parasomnia Obstructive sleep apnea syndrome |
| Benign thundercla headache | 0.3% (primary thunderclap) | Suggested to be more prevalent in elderly Acute onset, severe headache, sometimes accompanying symptoms | Simple analgesics | Not necessary | Exclude underlying intracranial pathology |