This is a moderately severe cranial pain that remains on one side and may fluctuate in severity. It is accompanied by autonomic features such as conjunctival injection or lacrimation, nasal congestion and runny nose, or ptosis. As mentioned earlier, it is responsive in most instances to indomethacin but escalating doses may be required, or a partial response may be expected from other nonsteroidal agents if gastrointestinal side effects are excessive. The clinical similarities to cluster headache are evident.
This awkward term describes an unremitting generalized headache with a distinct and fairly rapid onset the inception of which can be clearly recalled by the patient. Many cases follow a viral illness, stressful situation or non-cranial surgery as noted in the series reported by Li and Rozen. The IHSS classification requires that it last for over three months. It has a female preponderance but no special clinical, imaging or CSF features. The laterality and cephalic autonomic features of hemicrania continua are lacking. Treatment is largely unsatisfactory but antiepileptic agents may be tried.
Headaches in the Elderly
In several surveys, headache with onset in the elderly age period was found to be a prominent problem in as many as 1 of 6 persons, and more often to have serious import than headache in a younger population. In a series reported by Pascual and Berciano, more than 40 percent were classified as having tension headaches (women more than men), and there was a wide variety of diseases in the others (posttraumatic headaches, cerebrovascular disease, intracranial tumors, cranial arteritis, severe hypertension, and in our experience, subdural hematomas). Cough-induced headaches and cluster headaches were present in some of the men. New-onset migraine in this age group was a rarity.
Raskin described a headache syndrome in older patients that shares with cluster headache a nocturnal occurrence (hypnic headache). It also may occur with daytime naps. However, it differs in being bilateral and unaccompanied by lacrimation and rhinorrhea. He has successfully treated a number of his patients with 300 mg of lithium carbonate or 75 mg of sustained-release indomethacin at bedtime. The nosologic position of this hypnic headache syndrome is undetermined.
Despite these considerations, the most hazardous cause of headache in the elderly is temporal (cranial) arteritis with or without polymyalgia rheumatica, as discussed further on.
The most common cause of generalized persistent headache, both in adolescents and adults, is probably mild depression or anxiety in one of its several forms. A small group of older patients has delusional symptoms involving pain and physical distortion of cranial structures. As the psychiatric symptoms subside, the headaches usually disappear. Odd cephalic pains, for example, a sensation of having a nail driven into the head (clavus hystericus), may occur in hysteria or psychosis and raise perplexing problems in diagnosis. The bizarre character of these pains, their persistence in the face of every known therapy, the absence of other signs of disease, and the presence of other manifestations of psychiatric disease provide the basis for correct diagnosis. Older children and adolescents sometimes have peculiar behavioral reactions to headache: screaming, looking dazed, clutching the head with an agonized look. Usually, migraine is the underlying disorder in these cases, the additional manifestations responding to therapeutic support and suggestion.