What is the diagnosis for a 74-year-old female with persistent headaches after a forehead trauma, with a computed tomography (CT) cranial scan without contrast showing no acute intracranial pathology, but mild venous angiopathy?

From the Guidelines

For a 74-year-old female with persistent headaches following head trauma several months ago, with a CT scan showing no acute intracranial pathology and only mild venous angiopathy, I strongly recommend further evaluation for cerebral venous thrombosis (CVT) given the high prevalence of headache as a symptom in CVT, as reported in the American Heart Association/American Stroke Association statement 1. Given the patient's symptoms of persistent headaches and the presence of mild venous angiopathy on CT scan, it is crucial to consider CVT as a potential diagnosis, as headache is the most common symptom in CVT, present in nearly 90% of patients 1. The clinical manifestations of CVT, including headache, increased intracranial pressure, and papilledema, particularly with the involvement of the superior sagittal sinus, should be carefully evaluated in this patient 1. Key considerations in the evaluation of this patient include:

• The location of the thrombosis and its potential impact on clinical manifestations
• The presence of focal neurological signs or symptoms referable to the affected region
• The possibility of CVT being confused with other medical conditions, such as idiopathic intracranial hypertension
• The importance of distinguishing CVT from other mechanisms of cerebrovascular disease, including the frequency of focal or generalized seizures and bilateral brain involvement 1. In terms of management, if CVT is confirmed, anticoagulation therapy should be considered, as it is the mainstay of treatment for CVT, despite the presence of intracranial hemorrhage in some cases 1. However, if CVT is ruled out, the patient's headaches could be managed with acetaminophen 650-1000 mg every 6 hours as needed, and non-pharmacological approaches such as adequate hydration, regular sleep patterns, stress reduction, and avoiding headache triggers should be emphasized. If headaches persist, consideration of other treatment options, such as amitriptyline or topiramate for prevention, may be necessary, and consultation with a neurologist would be appropriate 1.

From the Research

Patient Presentation

The patient is a 74-year-old female presenting with persistent headaches. She has a history of hitting her forehead on a kitchen cabinet a few months ago. A CT cranial without contrast was performed, which showed no acute intracranial pathology, but mild venous angiopathy.

Diagnostic Considerations

• The patient's symptoms and history suggest a possible secondary headache disorder, which is defined as a headache caused by an underlying medical condition 2.
• The CT scan results indicate mild venous angiopathy, which may be a contributing factor to the patient's headaches.
• However, the study by 3 suggests that imaging is generally not warranted for headaches, unless there are red flag features present.
• The patient's age and history of trauma to the head may be considered red flag features, which would warrant further evaluation.

Treatment Options

• The study by 2 recommends acute treatment of headaches with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.
• However, the patient's age and medical history should be taken into consideration when selecting a treatment option.
• The study by 3 emphasizes the importance of careful attention to avoiding too frequent administration of acute therapy to avoid medication overuse headaches.

Venous Angiopathy Considerations

• The study by 4 discusses the management of anticoagulation therapy, which may be relevant to the patient's mild venous angiopathy.
• The study by 5 suggests that aspirin may be effective in reducing the risk of recurrent venous thromboembolism, but this should be considered in the context of the patient's overall medical history and risk factors.

Imaging Considerations

• The study by 6 discusses the appropriate and safe use of diagnostic imaging, including the use of noncontrast head computed tomography for evaluating suspected stroke.
• The study suggests that imaging should be avoided in patients with uncomplicated headache syndromes, unless there are red flag features present.