headache ( ha ) continues to be one of the most frequent complaints in neurology offices today . the prevalence of primary ha declines steadily after the age of 40 , but secondary ha is more likely to be seen in the elderly [ 13 ] . in one series , 15  % of elderly patients who presented de novo with ha had a serious treatable disorder , such as subarachnoid hemorrhage , temporal arteritis , trigeminal neuralgia , or intracranial hemorrhage , whereas only 1.6  % of those under 65 had a similarly serious condition . hospital admissions for intracerebral hemorrhage have increased by 18  % in the past 10  years , probably as a reflection of older individuals whose hypertension is not adequately controlled . other contributing factors include the increased use of anticoagulant drugs and the increased prevalence of cerebral amyloid angiopathy . a recent study showed that ha improvement could be seen in 49  % of sleep apnea patients who were treated with continuous positive airway pressure ( cpap ) . the most common primary ha types in the elderly are tension , migraine , late - life migraine accompaniments , cluster , and hypnic ha [ 1 , 2 , 18 ] . tension ha is the most common primary ha type in the elderly , according to one door - to - door survey of 833 elderly subjects in italy . the 1-year prevalence rate for tension ha in that series was 44.5  % , compared with 11.0  % for migraine ha , 4.4  % for chronic daily ha , and 2.2  % for symptomatic ha . the american migraine study   showed that the prevalence of migraine ha was 25  % in 50-year - old women , whereas it was only 10  % in 70-year - old women . for 50-year - old men , the prevalence of migraine ha was about 8  % , and this fell to about 5  % by the age of 70  years . chronic daily ha is an important group that includes transformed migraine , chronic tension ha , and hemicrania continua . in a large epidemiologic study in spain , the prevalence of chronic daily ha in older women ( > 60 ) was 11.3  % ( a much higher prevalence rate than that seen in women in general , which was 8.7  % ) . overuse of symptomatic medications was reported in 19  % of the chronic tension type ha patients in that series ( acetaminophen , aspirin , codeine , and caffeine ) . even more of the transformed migraine patients in that series ( 31  % ) overused drugs ( ergotamine , caffeine , and barbiturates ) . several of the patients in that series had been placed on chronic analgesics for non - ha indications , such as low back pain , demonstrating that ha - prone patients are vulnerable to developing rebound ha , even though they are being medicated for non - ha disorders . according to international headache society ( ihs ) , neither chronic migraine , nor medication - overuse ha can be diagnosed with confidence until medication has been withdrawn . if the medication - overuse ha diagnosis is correct , improvement should be expected within 2  months . medication may be seen as the cause of ha in as many as 8  % of patients who present with a ha complaint . nitroglycerine , for example , is a vasodilator that can trigger a nonspecific ha in non - migraineurs and a migraine - like ha in those who have a history of migraine . selective serotonin reuptake inhibitors , such as fluoxetine , paroxetine , sertraline , citalopram , and escitalopram have been commonly associated with drug - induced ha . venlafaxine , an inhibitor of serotonin , norepinephrine , and dopamine reuptake , has also been associated with drug - induced ha . migraine in younger persons usually presents with a ha or nausea complaint , whereas older individuals with migraine may develop other symptoms at onset , such as scintillating scotoma , traveling paresthesias , homonymous field defects , or speech disturbances [ 10 , 11 ] . typical features of these late onset migraine accompaniments are the buildup and spread of visual scintillations , spreading of the paresthesias from the hand to the face , and a progression from one accompaniment to the other . the total duration of migraine symptoms is usually 1530  min , whereas transient ischemic attacks ( tia ) in the vertebrobasilar system are shorter lasting ( less than 15  min ) . ha is present in about 50  % of patients who have migraine accompaniments , and a personal history and family history of migraine are often obtained from the patient . regional cerebral blood flow patterns in those who have migraine accompaniments are more likely to resemble age - matched controls than those who have posterior circulation tia . posterior circulation tias may have ha as one of the prodromal symptoms that precede stroke by days or weeks . in patients with basilar artery occlusion , these symptoms may occur as early as 2  weeks or more prior to the onset of stroke . a sudden , severe ha with maximum onset within 1  min and without evidence of subarachnoid hemorrhage (  thunderclap ha  ) can occur in association with any of the primary ha disorders , but other causes also need to be considered . thunderclap ha patients need a thorough set of neuro - imaging studies to rule out other possible diagnoses , such as an aneurysm , or cerebral venous thrombosis . primary thunderclap ha usually reaches its maximum intensity at 30  min and can last hours to weeks . they can be triggered by exercise , diving into cold water , walking into cold wind , or coughing . cough ha ( the primary , benign type ) is of sudden onset and lasts for 1  second to 30  min . it is usually bilateral and affects a predominance of male patients over the age of 40  years . cough ha begins significantly later than benign exertional ha , or benign vascular sexual ha . several cases of symptomatic cough ha were related to chiari type i malformation in the study of pascual et al . , so these patients all need to have mri scans with sagittal views to make the correct diagnosis . cluster ha , the most severe of all the primary ha disorders , can begin as late as 83  years of age . inheritance with cluster ha is autosomal dominant , but there is low penetrance in some families . in certain families , one patient may have cluster ha , while another person may have the autonomic symptoms without the ha . genetic anticipation has been seen in cluster ha families , so that the children of the probands have earlier onset of disease , and the symptoms become worse with each successive generation . hypnic ha awakens a patient from sleep and almost always begins after the age of 60 . the pain is usually dull and diffuse and lasts for 3060  min at a time . the pain of hypnic ha does not have lightening - like qualities to suggest the diagnosis of trigeminal neuralgia . hypnic ha can usually be prevented by taking coffee ( 12 cups ) or lithium ( 150600  mg ) prior to bedtime . cardiac ischemia can rarely be associated with a unilateral or bilateral ha that is brought on by exercise and is relieved by rest [ 1921 ] . when one obtains this history , a prompt referral to a cardiologist or to the emergency room is urgently needed . the choice of ha medication should be based on the type of ha that is being treated , the drug s efficacy , side effects , and costs . certain ha drugs , such as the triptans , can not be used in the older patients with established cardiovascular disease , since the risk of vasospasm is too high . compared with those with normal body mass index ( bmi ) , those with morbid obesity have a greater than two - fold increased odds of migraine . six months after bariatric surgery , the monthly ha frequency declined significantly [ 24 , 25 ] . some randomized trials have shown that migraine patients benefit from regular exercise , when it is offered as an alternative to relaxation therapy , or medication . intravenous magnesium ( 2  g over 10  min ) has been shown to be comparable to iv metoclopramide ( 10  mg over 10  min ) for acute migraine attacks . this drug plays a role in regulating vascular tone , which is thought to be important in migraine pathophysiology.standard dosage2  grams in 100  ml of normal saline / infused over 10  min.contraindicationknown adverse reaction to mgso4 ; altered mental status ; fever ; renal or cardiac disease.main side effectsaltered mental state ; hypotension ; arrhythmia . 2  grams in 100  ml of normal saline / infused over 10  min . known adverse reaction to mgso4 ; altered mental status ; in one double - blind study , iv metoclopramide had an efficacy of 67  % at 1  h , compared with 19  % with placebo . in another trial , iv metoclopramide was dosed up to 20  mg four times over 24  h without causing complaints of chest pain ( sq sumatriptan was the comparison group ) . efficacy in that study was 59  % at 2  h for metoclopramide , compared with 35  % for sq sumatriptan .standard dosage10  mg in 2  ml of saline over 10  min ( up to 80  mg in 24  h).contraindicationparkinson s disease or parkinson - plus syndrome.main side effectmotor restlessness , weakness , dizziness , drowsiness . 10  mg in 2  ml of saline over 10  min ( up to 80  mg in 24  h ) . intravenous ketorolac ( 30  mg over 30  min ) is a cyclooxygenase inhibitor that can reverse peripheral sensitization by inhibiting the neuroinflammatory cascade . it is more efficacious ( 60  % ) than sumatritan nasal spray for treating acute migraine ha . consider using a lower dose in older persons especially in someone with reduced renal function.standard dosage30  mg in 50  ml of saline or d5w over 30  min.contraindicationpatients already on anticonvulsants , antidepressants , or tranquilizers ; history of allergic reactions to nsaids ; pregnancy , use of alcohol.main side effectsdrowsiness , dizziness , nausea , and stomach pain . 30  mg in 50  ml of saline or d5w over 30  min . patients already on anticonvulsants , antidepressants , or tranquilizers ; history of allergic reactions to nsaids ; pregnancy , use of alcohol . valproic acid increases gamma - aminobutyric acid levels in the brain , which leads to inhibition of the trigeminal nerve activation . intravenous valproic acid ( 800  mg ) is comparable to iv lysine - acetylsalicylic acid ( 1000  mg ) at 24  h in acute migraine .standard dosage5001000  mg in 100  cc of normal saline infused over 30  min.contraindicationknown allergy to valproic acid , pregnancy , or liver disease.main side effectsnausea , sedation , diarrhea . 5001000  mg in 100  cc of normal saline infused over 30  min . there is strong , consistent support for the use of divalproex sodium for prevention of migraine ha [ 32 , 33 ] . there is level a evidence for efficacy , according to aan guidelines [ 34 ] . it is well tolerated in all age groups.standard dosage5001500  mg / d.contraindicationliver disease.main side effectsweight gain with long - term use ; teratogenic risk in young patients ; pancreatitis and liver failure in rare cases . weight gain with long - term use ; teratogenic risk in young patients ; pancreatitis and liver failure in rare cases . it is more effective than either placebo or lamotrigine ; it is equally effective , compared with propranolol   and sodium valproate .standard mg / d ( start 25  mg qhs for the first week , then use 25 mg bid for the first month ; if excessive daytime sedation develops , use 50 mg qhs).contraindicationkidney stones.main side effectsparesthesias , sleepiness , mild nausea , anorexia , weight loss , word - finding difficulties , and kidney stones ( patients need to be encouraged to drink plenty of water to prevent the kidney stones ) . 25200  mg / d ( start 25  mg qhs for the first week , then use 25 mg bid for the first month ; if excessive daytime sedation develops , use 50 mg qhs ) . paresthesias , sleepiness , mild nausea , anorexia , weight loss , word - finding difficulties , and kidney stones ( patients need to be encouraged to drink plenty of water to prevent the kidney stones ) . metoprolol ( 200  mg / d ) is more effective ( 45  % ) than aspirin ( 30  % ) ( 300  mg / d ) in reducing ha frequency in patients with migraine .standard dosage100200  mg / d.contraindicationchronic lung disease , asthma , congestive heart failure.main side effectsdizziness , fatigue , impotence , wheezing . propranolol ( 80  mg / d ) is more effective than placebo in reducing ha frequency and severity .standard dosage4080  mg / d.contraindicationchronic lung disease , asthma , congestive heart failure.main side effectsdizziness , fatigue , impotence , wheezing . chronic lung disease , asthma , congestive heart failure .
opinion statementmost primary headaches in the elderly are similar to those in younger patients ( tension , migraine , and cluster ) , but there are some differences , such as late - life migraine accompaniments and hypnic headaches . 
 although migraine in younger persons usually presents with headache , migraine in older persons may initially appear with visual or sensory phenomena , instead of headache (  migraine accompaniments  ) . 
 hypnic headaches awaken patients from sleep , are short - lived , and occur only in the elderly . 
 the probability of secondary headache increases steadily with age . 
 secondary headaches include those associated with temporal arteritis , trigeminal neuralgia , sleep apnea , post- herpetic neuralgia , cervical spondylosis , subarachnoid hemorrhage , intracerebral hemorrhage , intracranial neoplasm , and post - concussive syndrome . 
 certain rescue treatments for migraine headache in younger individuals ( triptans or dihydroergotamine , for example ) should not be used in elderly patients because of the risk of coronary artery disease . 
 naproxen and hydroxyzine are commonly used oral rescue therapies for older adults who have migraine or tension headaches . 
 intravenous magnesium , valproic acid , and metoclopramide are all effective rescue therapies for severe headaches in the emergency room setting . 
 some effective prophylactic agents for migraine in younger patients ( amitriptyline and doxepin ) are not usually recommended for older individuals because of the risks of cognitive impairment , urinary retention , and cardiac arrhythmia . for these reasons , 
 the recommended oral preventive agents for migraine in older adults include divalproex sodium , topiramate , metoprolol , and propranolol . 
 oral agents that can prevent hypnic headaches include caffeine and lithium . 
 cough headaches respond to indomethacin or acetazolamide .