R. Allan Purdy MD, FRCPC, Professor of Medicine (Neurology), Dalhousie University, Halifax, NS.

Of all the neurological disorders, migraine is one of the most common and fascinating. In importance, the modern neurobiology of migraine places it among other major neurological conditions of a paroxysmal nature. Migraine occurs at all ages and is not uncommon in middle- and late-life. It can present with aura and no or little headache, and with or without a prior history of migraine in earlier life. Physicians seeing older patients with transient neurological symptoms and headache need to understand the role of migraine in the diagnosis and ensure no other sinister etiology exists or coexists.
Key words: migraine, aura, migraine accompaniment, acephalgic migraine, headache.

D'Arcy Little, MD, CCFP
Director of Medical Education, York Community Services, Toronto, ON,
and Academic Fellow, Department of Family and Community Medicine,
University of Toronto, Toronto, ON.

Introduction and Epidemiology
While symptom complaints tend to increase as the population ages due to age and comorbid conditions, the prevalence of headaches actually decreases in the elderly compared to their younger counterparts.^1,2,3 However, headache is still very common in this age group and causes significant morbidity. It is the 10th most common reported symptom in women, and the 14th most common symptom in men over the age of 65 living in the community.^1,2,3 A large cohort study found that 11% of women over the age of 65 years and 5% of men over this age reported frequent headaches.¹

While most (two-thirds of) headaches in the elderly result from benign causes such as tension-type, migraines and cluster headaches, one-third of headaches in this age group arise secondary to systemic disease and primary intracranial lesions.^2,4 This is significantly different from the situation in younger patients, where only 10% of headaches are caused by such significant conditions (Table 1).^2,4 Another difference in headaches between the young and old is the fact that even benign dysfunctional headaches (e.g. migraine, tension-type, cluster) can have an atypical presentation in the elderly.