With regard to the symptoms present in the different headache disorders, the IHS classification does not differentiate in terms of the age of the patients, even it is known and also generally accepted that migraine symptoms in children are quite different to those in adolescents. In general, migraine attacks in the elderly are less often accompanied by vomiting or strong nausea, the headache has a less pulsating character [48], and also the character is more tension type like (unpublished own observation). In this sense, aggravation of the headache by physical activity is also reported less often [48]. Acute medication seems to influence the attacks better than in younger patients [18]. Aura symptoms with headache but also without accompanying headache seem to occur more often in the elderly; in the group of 18–29-year-olds about 15.2 % have auras compared to 41 % of the patients aged 70 years and older [3, 18, 49]. It has not been investigated whether the increased proportion of elderly patients with aura symptoms is due to the fact that migraine with aura more often persists in older age than migraine without aura or really reflects new onset auras. Diagnostic problems can be that aura-like phenomena can also be triggered by cortical ischemia and therefore diagnostic tests may be necessary in each patient with aura for the first time or with changes in the symptoms of the aura compared to previous one. In the Framingham study, slightly more than 1 % of all subjects reported on visual migraine symptoms, mostly starting after the age of 50 years [46]. A clinical manifestation of migraine that has been discussed more often in recent years is so-called vestibular migraine. These patients report on spells of vertigo/dizziness with durations of seconds to days which are regularly accompanied by migraine-like headache in some patients. Vestibular migraine can occur in all age groups but on average the patients seem to be older than the typical migraine patient [26].

Since auras in particular are caused by a temporary dysfunction of cortical neurons it is speculated that migraine patients should be more prone to cognitive decline in old age than nonmigraine patients. But in contrast most studies do not show an age-related more rapid decline in cognitive functions in migraine patients [13, 20].

The mean age of patients with chronic migraine is about 41 years [1]; it has not been investigated if the proportion of patients over 65 years is larger in chronic migraine than in episodic migraine, but the available data suggest that older patients with migraine on average have headache on more days (41 % on 10–14 days/month) [3, 23]. In contrast, in the general German population only 15.5 % of migraine patients have headache on more than 6 days [37]. In general, the incidence of migraine strongly declines with increasing age, as does the male-to-female ratio which declines from 1:3 to 1:2 after the menopause [13].

Based on the data from a population-based study in Northern Italy, it is estimated that about 20 % of female migraine patients lose their migraine with every 10 years of lifetime after the menopause [35].

Concerning the acute attack treatment, the EFNS and the DMKG recommend the usual self-medication in older patients as well [10, 12]. Acetaminophen or the fixed-dose combination of acetaminophen, acetylsalicylic acid, and caffeine are the first choice in acute attack treatment, if there are no cardiac contraindications triptans can also be prescribed [13]. Preventive treatment is less often prescribed in the elderly but most of the regularly used drugs can be given. Tricyclic antidepressants should be avoided since the anticholinergic action of them may influence cognition, bladder function, and may cause cardiac arrhythmia. Flunaricine should also be avoided because of the risk of pharmacologically induced Parkinson syndrome. Topiramate and ß-blockers, candesartan, as well as onabotulinumtoxinA have no special risk in older patients. Nonpharmacological treatment options should be considered, especially in older patients with multimorbidity. Beside psychological relaxation techniques, aerobic training therapy and acupuncture are both useful. For acupuncture a Cochrane review found that the available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment [21, 22], but no subgroup analysis was done for older patients.

The prevalence of tension-type headache also declines with increasing age. In an epidemiological study in South Tyrol, the 12-month prevalence of episodic tension-type headache was 35.8 % and that of chronic tension-type headache was 2.1 % in patients older than 55 years [35]. Compared to the prevalence of migraine the decline in the prevalence with age is less in tension-type headache [16, 17] but it is not clear if that is due to a change in the clinical representation of migraine toward a more tension type-like headache with the consequence that some patients with migraine could be diagnosed as having tension-type headache. The clinical characteristics of tension-type headache in older patients do not differ from those in younger patients. It can also be problematic that most secondary headaches can be confused with tension-type headache. A consequence of this is that the diagnosis of primary tension-type headache in the elderly can only be established after exclusion of secondary headaches, such as medication overuse headache, idiopathic intracranial hypertension, and sleep apnea-associated headache. Sleep-associated apneas, in particular, are much more prevalent in the elderly. Prevalence rates of up to 30–80 % are reported in subjects older than 65 years (compared to 2–4 % in the general population) [19]. Clinically apnea-associated headache is characterized by a morning headache with a dull character strongly resembling tension-type headache [31]. It is estimated that about 30 % of all patients with sleep apnea report on such a morning headache. For the acute treatment of tension-type headache, the same recommendations as for migraine attacks can be made [12]. Acetaminophen or the fixed-dose combination of acetaminophen, acetylsalicylic acid, and caffeine is the first choice. There is no indication for the use of triptans and opioids. In the case of chronic tension-type headache, preventive treatment can be helpful. Nonpharmacological options, such as relaxation training, biofeedback, and aerobic training, should be tried first. Pharmacological options are tricyclic antidepressants (e.g., amitriptyline) and the selective serotonin and noradrenalin reuptake inhibitor venlafaxine; the side-effect profile is better for venlafaxine but more studies are reported for amitriptyline. Other less established options are mirtazapine and tizanidine [37]. No studies focusing on older patients have been published. A recent Cochrane review stated that acupuncture could be a valuable nonpharmacological tool in patients with frequent episodic or chronic tension-type headaches [21, 22].

In general, cluster headache can first manifest at any age and there are several reports with first clinical manifestation above the age of 65 years [11]. No studies concerning the clinical symptoms or treatment in the elderly have been published. The clinical manifestation does not seem to be different in older patients. One problem is that the most effective acute treatment sumatriptan 6 mg subcutaneously or zolmitriptan 5 mg nasally has not been tested in older patients and is not approved for patients older than 65 years. In about 70 % of the patients breathing 100 % oxygen, 8–10 l per minute, reduces the headache significantly in 5–20 min [24]. No efficacy and safety data for older patients have been published for preventive treatment. Most guidelines recommend verapramil in a dosage of 240–480 mg (if necessary even 720 mg or more), but, especially in older patients, this treatment has to be monitored very carefully because of the cardiac side effects of verapramil. Another substance used is lithium (serum level 0.6–0.8 mmol/l), which is useful in chronic and probably also in episodic cluster headache [38]. Careful monitoring of the kidney and thyroid function is important. The use of topiramate is less well documented, although some experience in older patients with seizures is available for this substance and the side-effect profile in older patients is not very different to that in younger patients.

Hypnic headache (IHS 4.9) is a primary headache which normally occurs almost only in patients older than 50 years. The reason for this is not known.

On average several years elapse before the diagnosis is established (average age 61 years) [8, 9]. Clinically the headache is characterized by headache attacks which occur out of sleep with a bifrontal pain of a moderate intensity and no autonomic signs. The headache lasts about 60 min and in some patients onset is associated with REM sleep. No changes in clinical characteristics with increasing age are reported. The pathophysiology is not clear. No randomized treatment studies have been published; most authors recommend caffeine (e.g., 200 mg at bedtime) or alternatively a single dosage of verapramil 40–80 mg or 50–150 mg indomethacin at bedtime) [10].