Management of Headache in the Elderly

International Classification of Headache Disorders

Free AccessBPAPA Case of Nocturnal Headache Swapan Dholakia, MD, Octavian C. Ioachimescu, MD, PhD Swapan Dholakia, MD Address correspondence to: Swapan Dholakia, MD, 250 North Arcadia Ave, Decatur, Ga 30030 E-mail Address: [email protected] Atlanta VA Medical Center, Decatur, Georgia; Emory University School of Medicine, Atlanta, Georgia Search for more papers by this author , Octavian C. Ioachimescu, MD, PhD Atlanta VA Medical Center, Decatur, Georgia; Emory University School of Medicine, Atlanta, Georgia Search for more papers by this author Published Online:December 15, 2018https://doi.org/10.5664/jcsm.7548SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONA 48-year-old man presented with a 4-month history of nocturnal headaches. The headaches were waking him up from sleep at about 2-hour intervals, occurring two to three times each night. The headaches were always nocturnal, approximately 30 minutes in duration; dull, moderate in intensity; bilateral, in the occipital and temporal regions, without photophobia, phonophobia, or nausea; and sometimes relieved by warm showers. He denied any restlessness, eye redness or excessive tearing, drooping of the eyelid, or nasal congestion. Blood pressure was normal during the headache episodes. Neurologic examination was unremarkable.He had a history of severe obstructive sleep apnea diagnosed more than 10 years ago, treated with bilevel positive airway pressure (BPAP). He was adherent to BPAP therapy, without residual daytime sleepiness or fatigue. His primary care practitioner prescribed propranolol and topiramate as preventive therapy for possible migraines, without any improvement.A BPAP device download showed 100% adherence to therapy, 7 to 8 hours usage per night, with residual apnea-hypopnea index of 1.2 events/h. Review of a recent split-night polysomnography revealed no indirect evidence of hypoventilation such as persistent hypoxia. The patient did not have a headache episode during this study. Brain magnetic resonance imaging was unremarkable.QUESTION: What is the cause of this patient's sleep-related headache?ANSWER: Hypnic headacheDISCUSSIONHypnic headache was first described by Raskin in 1988.1 It is an uncommon primary headache that develops exclusively during sleep and awakens the individual. In many patients, it occurs at the same time each night, earning the name “alarm clock headache.” Although the exact mechanism is not known, imaging studies have shown reduction in gray matter volume in the posterior hypothalamus.2 The International Classification of Headache Disorders, Third Edition (ICHD-3) beta version3 defines hypnic headaches as:Recurrent headache attacks, fulfilling the following criteria: developing only during sleep, and causing awakening;occurring on ≥ 10 days/month for > 3 months;lasting from 15 minutes up to 4 hours after waking;without cranial autonomic symptoms or restlessness;unexplained by another ICHD-3 diagnosis. Polysomnography data show that hypnic headache may arise from rapid eye movement or non-rapid eye movement sleep.4 Other primary headache disorders such as migraine, cluster headache, and chronic paroxysmal hemicrania can also be sleep related and must be differentiated from hypnic headaches. Secondary causes of headaches such as brain tumors or hypertension may mimic hypnic headaches; as such, head imaging and blood pressure monitoring have been recommended to rule these out.5 Caffeine could be used for either prophylaxis or acute pain relief, whereas lithium and indomethacin are used for prophylaxis.6Our patient met all the diagnostic criteria for hypnic headaches. He was started on indomethacin 50 mg twice a day, and the frequency of headaches improved from a nightly occur-rence to once a week.SLEEP MEDICINE PEARLSHypnic headache is a primary headache disorder that occurs exclusively during sleep.It must be differentiated from other causes of sleep-related headache and brain magnetic resonance imaging can help rule out an underlying structural etiology such as tumors.Medications used to treat hypnic headaches include caffeine, indomethacin, and lithium.DISCLOSURE STATEMENTWork for this article was performed at the Atlanta VA Medical Center. All authors have seen and approved the manuscript. The authors report no conflicts of interest.CITATIONDholakia S, Ioachimescu OC. A case of nocturnal headache. J Clin Sleep Med. 2018;14(12):2091–2092REFERENCES1 Raskin NHThe hypnic headache syndrome. Headache; 1988;288:534-536, 3198388. CrossrefGoogle Scholar2 Holle D, Naegel S, Krebs Set al.Hypothalamic gray matter volume loss in hypnic headache. Ann Neurol; 2011;693:533-539, 21446025. CrossrefGoogle Scholar3 Headache Classification Committee of the International Headache Society (IHS)The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia; 2013;339:629-808, 23771276. CrossrefGoogle Scholar4 Manni R, Sances G, Terzaghi M, Ghiotto N, Nappi GHypnic headache: PSG evidence of both REM- and NREM-related attacks. Neurology; 2004;628:1411-1413, 15111685. CrossrefGoogle Scholar5 Gil-Gouveia R, Goadsby PJSecondary “hypnic headache.”. J Neurol; 2007;2545:646-654, 17404778. CrossrefGoogle Scholar6 Diener HC, Obermann M, Holle DHypnic headache: clinical course and treatment. Curr Treat Options Neurol; 2012;141:15-26, 22072057. CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 14 • Issue 12 • December 15, 2018ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationAugust 15, 2018Submitted in final revised formSeptember 26, 2018Accepted for publicationSeptember 28, 2018Published onlineDecember 15, 2018 Information© 2018 American Academy of Sleep MedicinePDF download

BackgroundHeadache disorders are widely prevalent and pose a considerable economic burden on individuals and society. Globally, misdiagnosis and inadequate treatment of primary headache disorders remain significant challenges, impeding the effective management of such conditions. Despite advancements in headache management over the last decade, a need for comprehensive evaluations of the status of primary headache disorders in China regarding diagnosis and preventative treatments persists.MethodsIn the present study, we analyzed the established queries in the Survey of Fibromyalgia Comorbidity with Headache (SEARCH), focusing on previous diagnoses and preventative treatment regimens for primary headache disorders. This cross-sectional study encompassed adults diagnosed with primary headache disorders who sought treatment at 23 hospitals across China between September 2020 to May 2021.ResultsThe study comprised 2,868 participants who were systematically examined. Migraine and tension-type headaches (TTH) constituted a majority of the primary headache disorders, accounting for 74.1% (2,124/2,868) and 23.3% (668/2,868) of the participants, respectively. Medication overuse headache (MOH) affected 8.1% (231/2,868) of individuals with primary headache disorders. Over half of the individuals with primary headache disorders (56.6%, 1,624/2,868) remained undiagnosed. The previously correct diagnosis rates for migraine, TTH, TACs, and MOH were 27.3% (580/2,124), 8.1% (54/668), 23.2% (13/56), and 3.5% (8/231), respectively. The misdiagnosis of “Nervous headache” was found to be the most prevalent among individuals with migraine (9.9%, 211/2,124), TTH (10.0%, 67/668), trigeminal autonomic cephalalgias (TACs) (17.9%, 10/56), and other primary headache disorders (10.0%, 2/20) respectively. Only a minor proportion of individuals with migraine (16.5%, 77/468) and TTH (4.7%, 2/43) had received preventive medication before participating in the study.ConclusionsWhile there has been progress made in the rate of correct diagnosis of primary headache disorders in China compared to a decade ago, the prevalence of misdiagnosis and inadequate treatment of primary headaches remains a veritable issue. As such, focused efforts are essential to augment the diagnosis and preventive treatment measures related to primary headache disorders in the future.

Headache is the pain of any kind or discomfort in the head excluding the lower part of the face and including the upper part of the neck. Of all the painful states that afflict humans, headache is undoubtedly the most frequent and the most common reason for medical consultation. Epidemiology of headache in Bangladesh is not exactly known but statistics from several countries may reflect the burden of headache all over the world as well as in our country. About 40 million Americans suffer from severe HA annually. Classification of Headache disorders are Primary Headache Disorders Secondary Headache Disorders. Primary headache disorders includes Migraine, Tension type of headache (TTH), cluster headache and other trigeminal autonomic cephalalgias, and others (hypnic headache, primary thunderclap headache, hemicrania continua, new daily-persistent headache (NDPH). Tension-type of headache is the most common variety of headache with one year prevalence has been variably reported from 30%-90%. Migraine is a common, frequently incapacitating, headache disorder characterized by episodic attacks of moderate-to-severe headaches, and various combinations of neurological, gastrointestinal and/or autonomic nervous system dysfunction. Cluster headache (CH) is a strictly unilateral .headache that occurs in association with crania autonomic features and, in most patients, has a striking circadian periodicity. Treatment of tension type of headache includes reassurance, symptomatic, prophylactic. Symptomatic treatment comprises analgesics e.g. paracetamole, NSAID, anxiolytic e.g. diazepam, other benzodiagipine (BNZ). The patient with a headache often finds himself a medical orphan. He is fortunate indeed if his headache is transient, for other wise he may find himself on an excursion to the ophthalmologist, otolaryngologist, neurologist, dentist, psychiatrist, chiropractor, and the latest health spa.

1. Heidi K. Blume, MD, MPH 1. Division of Pediatric Neurology, Seattle Children’s Hospital and Research Institute, Seattle, WA. * Abbreviations: CSF: : cerebrospinal fluid ICH: : intracranial hemorrhage ICP: : intracranial pressure IIH: : idiopathic intracranial hypertension NDPH: : new daily persistent headache NSAID: : nonsteroidal anti-inflammatory drug SVT: : sinus venous thrombosis TAC: : trigeminal autonomic cephalalgia Headaches are common in children; while most are caused by a benign problem or primary headache disorder, headaches can be a sign of a serious underlying condition. Pediatricians must be aware of the most recent recommendations for evaluating and managing headaches. After reading this article, readers should be able to: 1. Understand the evaluation of a child who has headache. 2. Recognize the diagnostic criteria for pediatric migraine. 3. Recognize “red flags” for elevated intracranial pressure or other underlying conditions in the child who has headache. 4. Discuss treatment strategies for migraine, tension, and chronic headache disorders. Headaches are common in children and adolescents and are a frequent chief complaint in office and emergency department visits. The vast majority of childhood headaches are due to a primary headache disorder, such as migraine, or an acute, relatively benign process, such as viral infection. However, clinicians also need to consider other causes of headaches in children. Even when headaches are benign, they may cause significant dysfunction for the child and family and must be managed appropriately to minimize disability and optimize function. In this review, we discuss the epidemiology of childhood headache, evaluation of the child who has headaches, when to consider secondary headache syndromes, and the diagnosis and management of primary headache disorders such as migraine and tension-type headaches. Acute and chronic headaches are relatively common in children and adolescents, although estimates of the precise prevalence of headache and migraine vary widely. Depending on the study definition of headache, population involved, and time periods studied, 17% to 90% of children report headaches, with an overall prevalence of 58% reporting some form of headache in the past year. (1 …

Applying the International Classification of Headache Disorders to the Emergency Department: An Assessment of Reproducibility and the Frequency With Which a Unique Diagnosis Can Be Assigned to Every Acute Headache Presentation

Background and PurposeNew-onset headache in elderly patients is generally suggestive of a high probability of secondary headache, and the subtypes of primary headache diagnoses are still unclear in the elderly. This study investigated the characteristics of headache with an older age at onset (≥65 years) and compared the characteristics between younger and older age groups.MethodsWe prospectively collected demographic and clinical data of 1,627 patients who first visited 11 tertiary hospitals in Korea due to headache between August 2014 and February 2015. Headache subtype was categorized according to the International Classification of Headache Disorders, Third Edition Beta Version.ResultsIn total, 152 patients (9.3%, 106 women and 46 men) experienced headache that began from 65 years of age [elderly-onset group (EOG)], while the remaining 1,475 patients who first experienced headache before the age of 65 years were classified as the younger-age-at-onset group (YOG). Among the primary headache types, tension-type headache (55.6% vs. 28.8%) and other primary headache disorders (OPH, 31.0% vs. 17.3%) were more common in the EOG than in the YOG, while migraine was less frequent (13.5% vs. 52.2%) (p=0.001) in the EOG. Among OPH, primary stabbing headache (87.2%) was more frequent in the EOG than in the YOG (p=0.032). The pain was significantly less severe (p=0.026) and the frequency of medication overuse headache was higher in EOG than in YOG (23.5% vs. 7.6%, p=0.040).ConclusionsTension-type headache and OPH headaches, primarily stabbing headache, were more common in EOG patients than in YOG patients. The pain intensity, distribution of headache diagnoses, and frequency of medication overuse differed according to the age at headache onset.

The objective is to summarize the knowledge on the epidemiology, pathophysiology and management of secondary headache attributed to SARS-CoV-2 infection and vaccination; as well as to delineate their impact on primary headache disorders. This is a narrative review of the literature regarding primary and secondary headache disorders in the setting of COVID-19 pandemic. We conducted a literature search in 2022 on PubMed, with the keywords "COVID 19" or "vaccine" and "headache" to assess the appropriateness of all published articles for their inclusion in the review. Headache is a common and sometimes difficult-to-treat symptom of both the acute and post-acute phase of SARS-CoV-2 infection. Different pathophysiological mechanisms may be involved, with the trigeminovascular system as a plausible target. Specific evidence-based effective therapeutic options are lacking at present. Headache attributed to SARS-CoV-2 vaccinations is also common, its pathophysiology being unclear. People with primary headache disorders experience headache in the acute phase of COVID-19 and after vaccination more commonly than the general population. Pandemic measures, forcing lifestyle changes, seemed to have had a positive impact on migraine, and changes in headache care (telemedicine) have been effectively introduced. The ongoing COVID-19 pandemic is a global challenge, having an impact on the development of secondary headaches, both in people with or without primary headaches. This has created opportunities to better understand and treat headache and to potentiate strategies to manage patients and ensure care.

Primary headache disorders are the most common complaints worldwide. The socioeconomic and personal impact of headache disorders is enormous, as it is the leading cause of workplace absence. Headache patients’ consultations are increasing as the population has increased in size, live longer and many people have multiple conditions, however, access to specialist services across the UK is currently inequitable because the numbers of trained consultant neurologists in the UK are 10 times lower than other European countries. Additionally, more than two third of headache cases presented to primary care were labelled with unspecified headache. Therefore, an alternative pathway to diagnose and manage patients with primary headache could be crucial to reducing the need for specialist assessment and increase capacity within the current service model. Several recent studies have targeted this issue through the development of clinical decision support systems, which can help non-specialist doctors and general practitioners to diagnose patients with primary headache disorders in primary clinics. However, the majority of these studies were following a rule-based system style, in which the rules were summarised and expressed by a computer engineer. This style carries many downsides, and we will discuss them later on in this dissertation. In this study, we are adopting a completely different approach. The use of machine learning is recruited for the classification of primary headache disorders, for which a dataset of 832 records of patients with primary headaches was considered, originating from three medical centres located in Turkey. Three main types of primary headaches were derived from the data set including Tension Type Headache in both episodic and chronic forms, Migraine with and without Aura, followed by Trigeminal Autonomic Cephalalgia that further subdivided into Cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. Six popular machine-learning based classifiers, including linear and non-linear ensemble learning, in addition to one regression based procedure, have been evaluated for the classification of primary headaches within a supervised learning setting, achieving highest aggregate performance outcomes of AUC 0.923, sensitivity 0.897, and overall classification accuracy of 0.843. This study also introduces the proposed HydroApp system, which is an M-health based personalised application for the follow-up of patients with long-term conditions such as chronic headache and hydrocephalus. We managed to develop this system with the supervision of headache specialists at Ashford hospital, London, and neurology experts at Walton Centre and Alder Hey hospital Liverpool. We have successfully investigated the acceptance of using such an M-health based system via an online questionnaire, where 86% of paediatric patients and 60% of adult patients were interested in using HydroApp system to manage their conditions. Features and functions offered by HydroApp system such as recording headache score, recording of general health and well-being as well as alerting the treating team, have been perceived as very or extremely important aspects from patients’ point of view. The study concludes that the advances in intelligent systems and M-health applications represent a promising atmosphere through which to identify alternative solutions, which in turn increases the capacity in the current service model and improves diagnostic capability in the primary headache domain and beyond.

34 - Headaches

Post-traumatic headache (PTH) is among the most prevalent of the secondary headache disorders. As currently classified by the International Classification of Headache Disorders, 2nd edition (ICHD-2), PTH must start within 7 days of a mild, moderate, or severe traumatic brain injury (TBI). PTH transitions from an acute subtype to a chronic subtype 3 months after the injury (1). No other defining clinical characteristics set PTH apart from other primary or secondary headache disorders. In fact, most PTHs appear to have a phenotype indistinguishable from primary headache disorders and may respond to the same treatments as primary headache disorders (2,3). It seems altogether intuitive that headaches would occur acutely in the majority of individuals after a mild TBI (or concussion). More vexing, and controversial, is the link between head trauma and the subsequent development of chronic headaches (4,5). PTHs persist beyond the acute period in a significant proportion of patients. Up to 60% of TBI patients have chronic headaches persisting for up to 12 months (4,6). That chronic PTHs develop more often in mild versus moderate to severe TBI, in cases with impending litigation or in the setting of analgesic medication overuse, suggests a role for factors independent of trauma in the process of headache chronification (4,7,8). While each (or all) of these factors may be important in the genesis of chronic headaches in individual cases, there is a lack of evidence supporting them as unifying hypotheses to explain the spectrum of chronic PTHs in civilian and military patient populations. A better understanding of the processes leading to headache chronification after brain trauma is needed. Over the past 3 years, large epidemiological studies of headaches in military, civilian, and veteran populations with head trauma have been completed (9–11), providing a valuable opportunity to better understand and classify PTHs. In this issue, Lucas et al. (10) report the findings of a multi-center, longitudinal study of headaches in a population of 378 patients with moderate to severe TBI. The subjects underwent a baseline headache evaluation shortly after TBI and were then followed by telephone interview at 3, 6, and 12 months after injury to longitudinally assess headache incidence and headache characteristics. To our knowledge, this is one of the largest longitudinal studies of headaches in TBI patients. Many interesting findings emerge from this study, parts of which have been published previously (10, 11). The cumulative headache incidence in the study cohort was 71% over 12 months. Forty-three percent of patients had headaches at the baseline assessment shortly after TBI and this proportion was stable over the next 12 months. There were no differences in headache incidence between mild, moderate, and severe TBI patients. Eighteen percent of all patients had a history of headaches prior to TBI with 57% of these being migraine or probable migraine. Similar to previous studies, pre-traumatic headache and female sex were risk factors for reporting headaches after TBI. Migraine and probable migraine were the most common headache types after trauma, accounting for 52% of headaches at baseline and 60% of headaches 6 months after injury. Migrainous headaches were 2–3fold more common than tension-type headaches (TTHs; 7–21%) at all time points. The high prevalence of migraine observed by Lucas et al. (10) sharply contrasts with older studies which suggested a higher prevalence of TTH after TBI, but are similar to the findings of recent studies in military and veteran populations which found migraine in 60 to over 90% of cases (2,3,9,12). Comparing PTH studies and study populations can be difficult, but the accumulation of

Although secondary headaches due to e.g. temporal arteritis or a brain tumor are common among the elderly, primary headache disorders also occur in this age group, albeit less frequently than in younger individuals. A different presentation in the older age groups often makes a diagnosis difficult. Some headache syndromes, such as hypnic headache, are typical for the elderly. Furthermore, age-related physiologic changes, co-morbidities and contra indications require appropriate and targeted treatment in the elderly. Although treatments for the most common primary headaches are available, many limitations hamper their use in this group. For many headaches syndromes randomized controlled treatment trials in elderly are not available. In this article we review the clinical aspects of common primary headaches and medication overuse headache in the elderly and their treatments, with emphasis on age-specific problems.Relevance for patients: Primary headache syndromes in older patients ask for specific treatment considerations due to comorbidity, polypharmacy and an increased risk of side effects. Clinically, the headaches can be different and atypical. Results from clinical trials cannot be generalized to the elderly because these groups usually are not included in studies. In migraine, non-pharmacologic treatment should be considered, with depression and cerebrovascular disease as major comorbidities. Tension type headache, being the most common headache presentation in elderly, also includes a relatively large proportion of patients with a secondary headache warranting further testing. Trigeminal autonomous cephalalgias are rare, and can present with pseudo dementia. Medication overuse and medication-induced headaches are relatively common, for which patient education, ceasing drugs and withdrawal from caffeine containing substances are pivotal. Furthermore, hypnic headache, exploding head syndrome and benign thunderclap headache are specific for this patient group and require specific treatment.

Migraine

The ‘Other Primary Headaches’ include eight recognised benign headache disorders. Primary stabbing headache is a generally benign disorder which often co-exists with other primary headache disorders such as migraine and cluster headache. Primary cough headache is headache precipitated by valsalva; secondary cough has been reported particularly in association with posterior fossa pathology. Primary exertional headache can occur with sudden or gradual onset during, or immediately after, exercise. Similarly headache associated with sexual activity can occur with gradual evolution or sudden onset. Secondary headache is more likely with both exertional and sexual headache of sudden onset. Sudden onset headache, with maximum intensity reached within a minute, is termed thunderclap headache. A benign form of thunderclap headache exists. However, isolated primary and secondary thunderclap headache cannot be clinically differentiated. Therefore all headache of thunderclap onset should be investigated. The primary forms of the aforementioned paroxysmal headaches appear to be Indomethacin sensitive disorders. Hypnic headache is a rare disorder which is termed ‘alarm clock headache’, exclusively waking patients from sleep. The disorder can be Indomethacin responsive, but can also respond to Lithium and caffeine. New daily persistent headache is a rare and often intractable headache which starts one day and persists daily thereafter for at least 3 months. The clinical syndrome more often has migrainous features or is otherwise has a chronic tension-type headache phenotype. Management is that of the clinical syndrome. Hemicrania continua straddles the disorders of migraine and the trigeminal autonomic cephalalgias and is not dealt with in this review.

Introduction: Headache disorders are among the most common health conditions worldwide, with a significant global burden, particularly from primary headaches such as migraine and tension-type headache (TTH). In Nepal, the prevalence of headache disorders is high, with a considerable portion of the population affected by these conditions. Primary headache disorders have been shown to negatively impact the quality of life (QoL) of individuals, both physically and mentally. Objective: This study aimed to assess the quality of life in patients diagnosed with primary headache disorders, including migraine, TTH, and other related conditions, at the Tribhuvan University Teaching Hospital in Nepal. Materials and methods: An observational descriptive cross-sectional study design was used, with a sample size of 211 patients diagnosed with primary headache disorders. Participants were selected using a non-probability convenience sampling method. A structured questionnaire was administered to collect demographic, clinical, and QoL-related data. The Quality of Life was measured using the Short Form (SF-36) questionnaire, which provides two key summary measures: the Physical Component Summary (PCS) and Mental Component Summary (MCS). Data was analyzed using SPSS Version 29, employing descriptive statistics, independent t-tests, ANOVA, and multiple linear regression to identify associations and predictors of QoL. Results: Preliminary results indicate that primary headache disorders significantly impair both the physical and mental health of affected individuals, as evidenced by lower PCS and MCS scores. Factors such as age, duration of illness, type of headache disorder, and medication use were identified as key determinants influencing the quality of life in these patients. Conclusion: The findings of this study highlight the substantial impact of primary headache disorders on the quality of life of individuals. Understanding the factors that contribute to the reduced QoL in these patients is crucial for developing effective interventions and improving the management of primary headache disorders in Nepal.