Headache Help (33 page)

As with younger people, however, migraines, tension, and cluster headaches are also the primary headache types in people over fifty. Although headaches in older people generally are treated the same way as for younger people, some medications are not used as often. Anti-inflammatories, for example, tend to be used less often because of greater kidney and gastrointestinal problems in older people. The Cox-2 inhibitors (Celebrex, Vioxx) may be less of a problem. Triptans are used sparingly and only for people with minimal heart risk factors.

MIGRAINES AFTER AGE FIFTY

Because preventive and abortive medications for migraines are generally the same as for younger people, we will discuss only the exceptions here.

T
REATING
M
IGRAINES IN
P
ROGRESS

If you get a migraine, put a cold pack on the pain and rest in a dark, quiet room. If you need medication, however, your doctor will need to assess your medical conditions, such as whether you have heart risk factors, tend to experience nausea, or have the potential for addiction. Because small doses of triptans are usually used only if you have no (or minimal) heart risk factors (tell your doctor immediately if you experience any chest pains), and DHE is used increasingly sparingly for older patients, doctors tend to use the pain medications more. The anti-inflammatories, such as naproxen, are used cautiously because they tend to upset stomachs. The COX-2 inhibitors (Celebrex, Vioxx) may help. Vioxx may prove to be an outstanding medication in older age ranges.

If you don’t have high blood pressure, your doctor might suggest Midrin; the doctor might also suggest low doses of one of the butalbital compounds (Fiorinal, Fioricet, Esgic, Phrenilin, Fiorinal with codeine, Fioricet with codeine), or narcotics such as hydrocodone or codeine. Occasionally, a sedative such as a benzodiazepine (such as Valium) may be helpful. If you experience nausea, tell your physician. Excedrin Migraine is an extremely effective OTC “as-needed” medication. It is usually well tolerated, but the caffeine can exacerbate insomnia and anxiety.

If you don’t have any heart risk factors, Migranal (DHE) nasal spray may help by constricting blood vessels. In general, ergotamines such as Ergomar or Cafergot are not used for older people. After age seventy, mild narcotic medications are often used be cause of their relative safety. Phrenilin, a butalbital compound, might be useful for older people because it doesn’t contain any aspirin or caffeine.

F
IRST
-L
INE
M
IGRAINE
P
REVENTION

The first-line medications to prevent migraines are the same as described in Chapter 6 except that naproxen, an anti-inflammatory, is used less for older people. Although anti-inflammatories are generally fine for use on an “as-needed” basis, taking them on a daily basis to prevent migraines is probably not a good idea. Thus, the first-line migraine preventives are: amitriptyline (or other antidepressants), propranolol (or other beta-blockers), Depakote, and verapamil. In choosing which first-line medication is most appropriate for you, your doctor will want to assess whether anxiety, depression, insomnia, stomach problems, heartburn, inflammatory bowel syndrome, arthritis, or high blood pressure are conditions that bother you.

S
ECOND- AND
T
HIRD
-L
INE
M
IGRAINE
P
REVENTION

If the above medications don’t work, your doctor may consider combining two of them, or prescribing Neurontin. Neurontin is an excellent and safe medication that’s now being widely used for pain and headaches. Methysergide (Sansert) is usually not an appropriate option if you’re over fifty. If these strategies don’t work or aren’t appropriate for you, third-line medications include MAO inhibitors, such as phenelzine, and repetitive intravenous DHE injections. These strategies, however, are used with great caution among older people. An NSAID may also be a third-line approach. (Also see Chapter 6.)

QUICK REFERENCE GUIDE: PREVENTING MIGRAINES AFTER AGE FIFTY

FIRST-LINE MEDICATIONS

1. A
   MITRIPTYLINE (OR OTHER ANTIDEPRESSANTS
   )
       Also helps daily headaches and insomnia. SSRIs (Prozac, Zoloft, Paxil) have fewer side effects.
   
2. PROPRANOLOL (OR OTHER BETA-BLOCKERS)
       Dosing is only once a day, but sedation, diarrhea, gastrointestinal upset, and weight gain are common.
   
3. V
   ERAPAMIL
       Once-a-day dosing. Nonsedating, and weight gain is uncommon, but constipation is common.
   
4. V
   ALPROATE (DEPAKOTE)
       Effective, but can cause fatigue or weight gain.
   

SECOND-LINE MEDICATIONS

1. TWO OF THE ABOVE MEDICATIONS
   
2. NEURONTIN
       An excellent and safe medication that may cause sedation or dizziness.
   

THIRD-LINE MEDICATIONS

1. PHENELZINE, AN MAO INHIBITOR
       Powerful and very helpful when depression, anxiety, or panic attacks are also a problem. Not appropriate if you have high blood pressure. Potentially serious side effects.
   
2. REPETITIVE
   IV DHE
   INJECTIONS
       Used with great caution among older people. Various side effects possible. (See Chapter 6.)
   
3. NSAIDS
       One of the last choices because of stomach upset and kidney effects. The COX-2 inhibitors (such as Vioxx) don’t irritate the GI tract as much and may help.
   

TENSION HEADACHES AFTER AGE FIFTY

As we discussed in Chapters 8 and 9, tension headaches are common at all ages, and it’s unfortunate that the name implies that tension and stress are at the root of the head pain. In fact, stress and tension may aggravate an underlying headache problem, but they are usually not the cause. The vast majority of people who get daily headaches also suffer from migraines. After age fifty, though, the migraines tend to wane, leaving a chronic daily headache.

If you are getting tension headaches less than twice a week, your doctor will probably recommend the strategies and medications discussed in Chapter 8. If you have them almost daily, you need to be careful about taking an analgesic almost every day, because doing so can make your headaches worse (see the rebound headache section in Chapter 1). If the headaches are interfering with your quality of life, however, you might ask your doctor about preventive medications.

As discussed in Chapter 9, the first-line medication used is an antidepressant, whether you’re depressed or not. For older people, however, nortriptyline (Pamelor) rather than amitriptyline is generally the first medication tried because, although it’s less effective, its side effects are milder. Other antidepressants, such as the SSRIs, are sometimes good choices, too. The NSAIDs are not a second choice for people over age fifty, because of the higher risk of kidney and gastrointestinal problems. With these exceptions, therapies are generally the same as those discussed in Chapter 9.

CLUSTER HEADACHES AFTER AGE FIFTY

Treatment for cluster headaches in older people is the same as that described in Chapter 10, except that fewer ergotamines (except DHE) are used. Imitrex is by far the most effective treatment. After age fifty, however, coronary artery disease (CAD), high cholesterol, diabetes, family histories of CAD, and smoking history become increasingly important with these medications. The standard older ergotamines, except for DHE, are hardly ever recommended for people over fifty. DHE, usually in the form of Migranal Nasal Spray, is sometimes useful.

In preventing cluster headaches, the discussion in Chapter 10 generally holds true for older people, with the exception of using Sansert, which is only minimally helpful for cluster headaches, and is usually not used for older people.

OTHER COMMON CAUSES OF HEADACHES IN OLDER PEOPLE

B
LOCKED
A
RTERIES

One condition that causes headaches among people of advancing age, after migraines and tension-type headaches, is blockage of an artery that supplies blood to the brain. If the sufferer is left untreated, weakness, numbness, confusion, impaired vision, difficulty with speech, or other similar signs of dysfunction may follow. This is a serious condition and requires immediate medical attention.

H
YPERTENSION

High blood pressure may cause headaches, especially in the morning. Medication should be taken to keep pressure in check. The blood pressure usually needs to be fairly high (more than 170/100) to increase headaches.

T
EMPORAL
A
RTERITIS

This rare headache that usually afflicts only older people involves an inflammation of the temporal artery. There is a jabbing, burning pain around an ear. Other symptoms often include a low-grade fever, problems with eyesight, weight loss, and pain on one side of the jaw. Doctors still don’t know the cause of these headaches, but if you experience these symptoms, see your doctor. Serious com plications, such as blindness, could develop if you don’t. Steroids are usually the treatment of choice.

T
IC
D
OULOUREUX
(T
RIGEMINAL
N
EURALGIA
)

Also rare, these head pains are most common in women over age fifty-five. They are sharp, short, jabbing pains in the face, near the mouth or jaw. The pain, which may last from several seconds to one minute, striking many times during the day, is caused by a disease of the neural impulses. Typical treatment involves anticonvulsants, muscle relaxants, and sometimes neurosurgery or freezing of the nerve.

A
RTHRITIS IN THE NECK

Arthritis may cause a low-grade, back-of-the-head ache. Physical therapy and stretching exercises may help. Anti-inflammatories may be useful, but can lead to stomach upset or ulcers. The new NSAIDs, such as Vioxx, cause less stomach bleeding or ulcers.

13

Less Common Headaches and Treatments

I
N THIS CHAPTER
, we’ll look at other kinds of headaches that are actually less common, though some are very well known, such as sinus headaches and sexual headaches. In most cases, these headaches are named for their triggers and are similar to the types of headaches we have discussed so far. Nevertheless, many people identify their headache by its triggers, so it’s useful to address each one separately.

POST-TRAUMATIC HEADACHE

Headaches are very common after a rear-end car accident, whether or not your head or neck was injured in the collision. This is particularly true if you have suffered from headaches before. Usually these headaches develop within hours or days of the accident, although occasionally they may begin months later. In most cases, the headaches will taper off within a few days to several weeks. However, even minor accidents can produce very severe, long-lasting headaches of up to a year or more.

Post-traumatic headaches are usually either tension-type headaches—daily or episodic—or more severe migraine-type headaches, or both. Neck and back-of-the-head pain are also very common. The pain comes from damage to muscles, ligaments, and occasionally to intervertebral discs. Tenderness or stiffness and pain in the neck and shoulder muscles are quite common. This pain may be resistant to therapy, but physical therapy or chiro practic manipulations may be helpful. Typical symptoms that may accompany these headaches are poor concentration, becoming easily angered or frustrated, sensitivity to noise or bright lights, depression, dizziness, ringing in the ears, memory problems, fatigue, insomnia, lack of motivation, lessening sexual drive, nervousness or anxiety, irritability, and decreased ability to comprehend complex issues.

It is difficult to predict who will continue to suffer chronic, unremitting post-traumatic pain after an accident. If you were in a rear-end collision but didn’t injure your head, you might still get severe headaches and neck pain. The angle of impact, where you were sitting in the car, and what happened to your brain within the skull are key elements in whether you’ll get headaches afterward.

The older you are, the more likely you are to develop posttraumatic headaches after an accident. Women are almost twice as likely to suffer from post-traumatic headaches as men. If you tended to get headaches or had migraine problems before the accident, or have a very strong family history of headaches, you also are at higher risk. Although the severity of your accident or injury might predict your likelihood of suffering post-traumatic headache, many people endure months or years of severe post-traumatic headaches after even very trivial collisions. Studies disagree as to whether many of these people exaggerate or malinger, although researchers have noted that even after other issues are settled (litigation, disability, worker’s compensation, insurance), most people continue having the same degree of symptoms, suggesting that few people actually fake their pain.