Headache in the Elderly: Careful Considerations for Primary and Secondary Causes

Ubiquitous and disabling, headache disorders are common — with an estimated prevalence of migraine in the United States between 11.7% and 22.7% — and are one of the leading causes of emergency department visits.^1,2

Evidence suggests a difference in prevalence of headache disorders between the elderly (≥65 years) and younger adults (˂65 years) that may have implications for treatment. Commonly reported primary headache disorders in the elderly include migraine headache, tension-type headache, cluster headache, and chronic daily headache.³ Although headache disorders have been reported to generally decrease with age, the prevalence of specific primary headache disorders appears to differ between older and younger adults. Specifically, the incidence of migraine and the accompanying symptoms of photosensitivity, nausea, and vomiting is lower in older adults compared with younger adults. In contrast, tension-type headache is more prevalent in older adults and secondary causes of headache become more significant.^3-5 

This difference in distribution of primary headache disorders between younger and older adults was demonstrated in a study by Song and colleagues, who reported that among 1627 patients with headache, tension-type headache, and other primary headache disorders, tension-type and other primary headache disorders, including stabbing headache, were more common in older adults, and migraine headache was less frequent.⁶

The approach to treating headache disorders in older adults can be challenging compared with younger adults, primarily because of the added complexity as a result of comorbidities, polypharmacy, and age-related physiologic changes. The potential changes in drug pharmacokinetics/pharmacodynamic properties, efficacy and toxicity profile, the increased risk for drug-drug interactions, and alterations in drug distribution and renal clearance⁵ suggest that dosage of headache treatment may need to be adjusted in this population, as side effects may be greater and some treatments may be contraindicated.

Medication overuse headache (MOH), a form of chronic migraine, can be a serious problem among older adults and is often associated with overuse of analgesics to manage primary pain conditions. A study by Pablo de Rijk and colleagues, based on a retrospective review of 239 records of people with migraine, reported high frequency of probable MOH, which correlated positively with younger age of migraine onset, suggesting a potential benefit for early initiation of preventive treatment in patients ˂65 years of age.⁷

Other studies have also reported an association of MOH with analgesic medication prescribed for the treatment of pain unrelated to headache, such as back or joint pain.^3,5 Overuse of analgesics and the potential confounding variable of anxiety and depression in this age group may lead to dependency and medication overuse, ultimately contributing to MOH. Indeed, MOH appears to be particularly prevalent in older adults with chronic pain, and population-based studies in older adults suggest that reducing acute pain medication and increasing use of prophylactic pain management may improve primary chronic headache management and possibly MOH.³

There is some speculation about whether the high frequency of probable MOH reported in the study by de Rijk and colleagues⁷ is a reflection of analgesic dependency or dependency on other medications used to treat comorbid conditions in this population. “While some [people with] chronic daily headache may have analgesic dependency, many others don’t,” Pablo de Rijk, MD, of Hopital de la Timone in Marseille, France, told Neurology Advisor. Patients with MOH are often categorized into 2 groups, Dr de Rijk said, “patients whose worsening of headaches induce the medication overuse with minimal psychiatric condition, and patients with addictive behavior (as defined in the Diagnostic and Statistical Manual of Mental Disorders-3), which accounts for around two-thirds of patients.”

In a review by Professor Aynur Özge, anxiety and depression were reported to be more prevalent in older adults with MOH compared with younger participants.³ Consequently, behavioral management for MOH may be useful.⁸ Professor Özge, of Mersin University School of Medicine in Turkey, told Neurology Advisor that “MOH is a part of the addiction. In my clinical practice, after the management of anxiety and major depressive state, we can cover the MOH easily.” She added that, “for some MOH patients, the overuse is linked to insufficient treatment efficacy, while for others, there is indeed an addiction. When you address the dependency, it will naturally help to manage the MOH.”

Given the unique challenges presented by aging, new cases of headache in older adults should be evaluated carefully for a differential diagnosis of primary headache and to exclude underlying causes of secondary headache. A thorough diagnostic workup may include neuroimaging, blood work, and cerebrospinal fluid analysis, depending on the headache characteristics and other medical risk factors. Accurate diagnosis of primary or secondary headache is critical for the appropriate selection of medication. Regardless of the specific headache disorder, treatment options may need to be limited and tailored to accommodate comorbid medical conditions. The high risk for adverse effects with current treatment options, including the risk for dependency and the increased prevalence of MOH, calls for the investigation of innovative new drugs and other headache treatment options that are safer in the elderly population.

References

1. Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: updated statistics from government health surveillance studies. Headache. 2015;55(1):21-34.
2. Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache. 2013;53(3):427-436.
3. Starling AJ. Diagnosis and management of headache in older adults. Mayo Clin Proc. 2018;93(2):252-262.
4. Semenov IA. Headache in the elderly. Dis Mon. 2015;61(6):249-250.
5. Özge A. Chronic daily headache in the elderly. Curr Pain Headache Rep. 2013;17(12):382.
6. Song TJ, Kim YJ, Kim BK, et al. Characteristics of elderly-onset (≥65 years) headache diagnosed using the international classification of headache disorders, third edition beta version. J Clin Neurol. 2016;12(4):419-425.
7. de Rijk P, Resseguier N, Donnet A. Headache characteristics and clinical features of elderly migraine patients [published online December 13, 2017]. Headache. doi: 10.1111/head.13247
8. Radat F, Creac’h C, Guegan-Massardier E, et al. Behavioral dependence in patients with medication overuse headache: a cross-sectional study in consulting patients using the DSM-IV criteria. Headache. 2008;48(7):1026-1036.