Headaches in Older Adults: Special Considerations and When to Seek Expert Care

When an older adult develops a new headache — or notices that an existing headache is changing in character — the clinical approach is fundamentally different from that applied to younger patients. In neurology, we treat any new headache after the age of 50, and particularly after 60, as requiring thorough evaluation until a benign cause is confirmed.

This is not because older adults are inherently more medically fragile, or because headaches in this age group are always serious. The majority are not. But the spectrum of causes is different, the likelihood of a secondary headache (one caused by another underlying condition) is higher, and some of the serious causes — like temporal arteritis or subdural haematoma — are far more common in older adults and require specific treatment.

Understanding this helps older adults and their families advocate effectively and know when to act quickly.

Why Headaches in Older Adults Deserve Special Attention

Primary headache disorders change with age: Migraine typically becomes less frequent and less severe after middle age — many women find migraine improves significantly after menopause. New-onset migraine after 50 is uncommon and should be evaluated. Tension-type headache continues but is usually long-established.

Secondary headaches become more common: The older the patient, the wider the range of conditions that can cause headache as a symptom — vascular disease, hypertension, medication effects, cervical spine disease, and intracranial pathology. A new headache in an older adult is secondary until proven otherwise.

Medications accumulate: Older adults often take multiple medications, and polypharmacy creates more opportunities for drug-headache interactions. Some antihypertensives, nitrate cardiac medications, and other drugs can cause or worsen headaches.

Comorbidities complicate management: Safe headache treatment in older adults must account for kidney and liver function, cardiovascular status, and drug interactions in ways that are less relevant in younger patients.

Important Conditions to Know About

Temporal Arteritis (Giant Cell Arteritis)

This condition is critical to recognise because it can cause sudden and permanent vision loss if untreated.

Temporal arteritis is an inflammatory condition of the blood vessels — most commonly the temporal arteries running along the sides of the scalp — that occurs almost exclusively in adults over 50, and most commonly in those over 70. The headache is typically:

• New onset, persistent, and located at the temples (sides of the scalp)
• Associated with scalp tenderness — combing hair or resting the head on a pillow may be painful
• Accompanied by jaw pain when chewing (jaw claudication)
• Accompanied by general symptoms: fever, weight loss, fatigue, shoulder or hip aching (polymyalgia rheumatica)

The danger: If the inflamed artery supplies the eye, sudden painless vision loss can occur, and it may be permanent if treatment is not started urgently.

If an older adult develops a new temporal headache with any of the above features — particularly jaw pain on chewing or any visual disturbance — this is a neurological emergency. Please seek care the same day.

Subdural Haematoma

A collection of blood between the brain and its outer covering, often following a head injury that may have been so minor it was not noticed or remembered. Older adults — particularly those on blood thinners — are at higher risk. The headache is typically gradual in onset, slowly progressive, and may be accompanied by mild confusion or personality change. If an older adult develops a slowly worsening headache in the context of any recent head trauma (even a minor bump), medical evaluation is essential.

Hypertension-Related Headache

Severely elevated blood pressure can cause headache, typically described as a pulsating morning headache, occipital (back of head) in location. Chronic mild-to-moderate hypertension does not usually cause headache. But if blood pressure is very high — and particularly in the context of hypertensive crisis — headache can be a symptom. Regular blood pressure monitoring is especially important for older adults with any new headache.

Medication-Related Headache

Common in this age group: nitrates used for cardiac conditions, certain antihypertensives, and long-term analgesic use can all cause headache as a side effect or through rebound mechanisms. Review of all current medications with a doctor is important when evaluating new headache in an older adult.

Warning Signs Requiring Immediate Medical Attention

Go to emergency immediately for:

• Thunderclap headache — sudden, explosive onset, worst headache of their life
• Headache with fever, stiff neck, and light sensitivity — possible meningitis (does occur in older adults)
• Headache following any head trauma, even minor
• Headache with new confusion, personality change, or reduced alertness
• Any visual disturbance — blurring, double vision, or vision loss — alongside new headache
• Headache with weakness, facial asymmetry, or speech difficulty — possible stroke

See a neurologist promptly for:

• Any new headache after age 60
• Scalp tenderness with temporal headache — temporal arteritis needs evaluation that same week
• Headache that is progressively worsening over days
• Headache consistently worse in the morning
• Headache in someone on anticoagulants or who has had a recent fall

Safe Management in Older Adults

Managing headache safely in older adults requires an individualised approach. I want to highlight a few important considerations:

Medication selection: Many commonly used headache medications require caution in older adults. NSAIDs (ibuprofen, diclofenac) can worsen kidney function, raise blood pressure, and increase bleeding risk — particularly in those on blood thinners or with cardiovascular disease. Triptans used for migraine need cardiovascular review before prescribing. Paracetamol (acetaminophen) is generally safer for acute use, but liver function matters. This is why self-medicating without medical review is particularly risky in this age group.

Non-pharmacological approaches: Physical therapy for cervical spine and posture-related headache, sleep hygiene, hydration, and stress management are effective and have no medication-related risks. In older adults, these are often my first line.

Cognitive overlap: Mild cognitive impairment or early dementia can make headache history unreliable — family members who observe the patient regularly often provide the most useful clinical information.

Dehydration: Older adults have reduced thirst sensation and are more prone to dehydration, which is a headache trigger. Regular fluid intake throughout the day, not just when thirsty, is a simple and effective preventive measure.

Common Questions

1. My elderly parent has started getting headaches for the first time — how worried should I be? A new headache in someone over 60 with no prior headache history deserves prompt evaluation. This does not mean it will turn out to be serious — tension-type headache can begin in older adulthood, and there are benign explanations — but new headache in this age group needs proper assessment to rule out secondary causes including giant cell arteritis, subdural haematoma, vascular changes, and medications. Please do not wait and see.

2. Could the headache be caused by my parent’s blood pressure medication? Yes, this is possible. Some antihypertensives — particularly calcium channel blockers — can cause headache, especially when the dose is changed or the brand varies. Equally, poorly controlled hypertension itself can contribute to headache. Review the timing of when headaches began in relation to any medication change, and raise this with the prescribing doctor.

3. My parent has dementia and cannot clearly describe their pain — how do we manage headache? Headache in people with cognitive impairment is genuinely challenging because the history is unreliable. Look for behavioural changes, facial grimacing, or changes in function that accompany possible headache episodes. Family observation is clinically valuable. Safe, appropriate pain management can be provided — the goal is comfort and quality of life.

4. Are over-the-counter pain medications safe for older adults? More caution is needed in older adults. NSAIDs (ibuprofen) carry meaningful risks including gastrointestinal bleeding, fluid retention, and kidney effects, particularly at higher doses or in those with kidney disease, heart failure, or on blood thinners. Paracetamol is generally safer but dose adjustments may be needed in those with liver disease. Please discuss regular use of any pain medication with a doctor rather than relying on self-management.

A Personal Note

I see older adults in my clinic who have been told their headaches are “just part of getting older” or who are reluctant to report symptoms because they do not want to be a burden on their family or the healthcare system. Neither of these is the right frame.

Age is not a reason to stop investigating or treating headache — it is a reason to investigate more carefully. Many causes of headache in older adults are very treatable, and quality of life matters as much at 70 as at 40. If you or an older family member is experiencing a new or changing headache, please seek evaluation. The relevant question is not “is this normal for their age?” but “what is causing this, and what can we do about it?”