A Pain in the Brain

WebMD Feature

April 23, 2001 -- She rarely got headaches. So when the pain began -- on the left side of her head, at the temple -- and didn't go away, she decided she might need medical attention. Her physician was glad she did.

After reviewing her medical history, noting that she had tenderness over the left temporal artery (a blood vessel along the side of the head), and ordering some tests, Stephen Ross, MD, chief of staff at Santa Monica-UCLA Medical Center, Santa Monica, Calif., and a UCLA assistant clinical professor of medicine, diagnosed a condition called temporal arteritis, an inflammation of the blood vessels that can lead to blindness, strokes, and even heart attack if left untreated. After a course of corticosteroids to calm the inflammation, the woman was fine, with no vision or other health problems.

That case history from Ross illustrates part of the good news-bad news story of headaches in middle age and later. While those who have suffered through young adulthood with migraines or cluster headaches often find they have fewer or no episodes as they age, some middle-aged and older people who have rarely taken headache medicine will experience what doctors call secondary headaches -- those caused by underlying disease or structural problems. And these headaches warrant medical attention to rule out serious problems.

The statistics

Overall, headaches remain a common symptom in older adults, according to Joel R. Saper, MD, founder and director of the Michigan Head Pain & Neurological Institute, Ann Arbor, who co-authored a report on geriatric headache, published in the December 2000 issue of the journal Geriatrics. Headache is the 10th most common symptom reported by women ages 65 and above, and the 14th most common symptom in men of that age range, according to the report by Saper and his colleague, David M. Biondi, DO, director of the institute's head pain division.

Many of these headaches will be caused by nothing more than tension. But what's distressing to Saper is the number of people in all age ranges who don't seek medical attention for their head pain.

"About 50% of people who have headaches pretty much self treat," he tells WebMD. "We advise against that in most cases. Clearly, pain is a symptom that something is wrong. It may not be serious." But a headache sufferer should consult a doctor and let the medical expert decide, he says.

Older adults should expect their headache pain to be taken just as seriously as that in younger people, Saper says. Some physicians treat older adults' headaches less aggressively, he says, chalking up the pain to depression or just a fact of life with age.

The evaluation

Older adults who experience severe headache for the first time after age 50 need a thorough medical evaluation, says Saper, who has co-authored a textbook, Handbook of Headache Management. The physician should obtain a detailed medical history.

Among the tests that may be considered: computed tomography (CT) or magnetic resonance imaging (MRI), along with evaluation of blood and urine and vision exams. Heart tests may be ordered if the headache is exercise-induced, which may suggest heart disease.

The diagnosis laundry list

What might cause severe headaches in older adults? Besides heart disease, if the headache is exercise-induced, or temporal arteritis, suffered by Ross' patient, there are many other possibilities.

Some headaches are induced by medication for high blood pressure, Parkinson's disease, chronic obstructive lung disease, and other conditions that are more common with age. Hormone replacement therapy can be associated with midlife headache, too, Saper says.

"I see many older women on hormone replacement therapy who got their first migraine after starting it," he says. But because HRT provides other benefits such as a reduction in heart disease risk, Saper does not generally recommend that women discontinue the treatment.

Headaches also can be a symptom of certain types of strokes.

Subdural hematomas, or bleeding in the brain, are another possibility.

Another patient of Ross got up in the middle of the night to use the bathroom, fell and struck her head, but went back to sleep, since she was not in great pain. Three days later, she sought help for a severe headache. The diagnosis: subdural hemotoma. "She ended up having to have neurosurgery," Ross says. "They drilled [small] holes to relieve the pressure."

Hypnic headache is another, more remote possibility. These headaches are marked by painful attacks that occur at night, waking the person. Pain occurs on both sides of the head and may be accompanied by nausea. There are often one or two episodes per night, each lasting five to 60 minutes. The good news: A dose of lithium prevents further attacks, Saper has found.

Brain tumor is a remote possibility. "In my experience, probably less than 1% of headaches are related to a brain tumor," Ross says. Still, fear of a brain tumor brings in many patients. Trying to sound casual, they'll ask him: "Doc, you don't think I have a brain tumor, do you?" He can be reassuring: Most likely they do not.

Saper says he is less likely to hear the fears about brain tumors, mostly because by the time patients get to his specialized clinic, they already have seen their primary care doctor.

"But everyone is worried when their headache hurts," he says.

Progress in treatment

There's more understanding of headache in older adults than in years past, Saper says. For instance, specialists recently have found that the neck may play a role in headaches in the later years. Cervical arthritis, for instance, might be a headache trigger and can be relieved by treatment of the arthritis.

"Another trend has been the recognition that as people get older, certain brain chemicals decrease," Saper says. So the headaches in those people are not caused by depression -- a common diagnosis in the elderly -- but to a decline in those chemicals. The headaches prove to be more physiological than psychological.

Treatment for headache pain will improve, Saper predicts, as more research is done on specific types of headaches. Several medications now being researched look promising, he says, because they target the specific brain pathway that triggers the headache.

Kathleen Doheny is a Los Angeles-based health journalist and regular contributor to WebMD. Her work also appears in the Los Angeles Times, Shape, Modern Maturity, and other publications.

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