From the Guidelines
For a 97-year-old patient presenting with headache, I strongly recommend ordering a noncontrast head CT as the initial diagnostic step, followed by a lumbar puncture if the CT is nondiagnostic, to rule out subarachnoid hemorrhage, as this condition is a medical emergency that can be frequently misdiagnosed 1. Given the patient's advanced age, it is crucial to consider the Ottawa SAH Rule, which suggests that patients with new severe nontraumatic headache reaching maximum intensity within 1 hour, especially those with neck pain or stiffness, witnessed loss of consciousness, onset during exertion, thunderclap headache, or limited neck flexion on examination, require additional investigation for subarachnoid hemorrhage 1. The patient's age and presentation should guide the decision to perform additional testing, including:
- Complete blood count (CBC) to evaluate for infection or inflammation
- Comprehensive metabolic panel (CMP) to assess electrolyte balance and renal function
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to evaluate for temporal arteritis or other inflammatory conditions
- Coagulation profile to assess bleeding risk
- Urinalysis to evaluate for urinary tract infection or other renal issues
- Medication review to identify potential contributors to headache It is essential to note that the Ottawa SAH Rule has been validated to be 100% sensitive but only 13.6% specific, indicating that while it can identify patients who are unlikely to have subarachnoid hemorrhage, it should not be relied upon solely to rule out the condition 1. Therefore, a comprehensive approach, including imaging and laboratory tests, is necessary to promptly diagnose and manage potential underlying causes of headache in this elderly patient, prioritizing morbidity, mortality, and quality of life as the primary outcomes.
From the Research
Labs for 97-year-old patient with Headache (HA)
When evaluating a 97-year-old patient presenting with headache, it's crucial to consider the differential diagnoses and the appropriate laboratory tests to order. The following points outline the key considerations:
- Primary vs. Secondary Headache: Most patients presenting with headache have primary headache disorders such as migraine, tension-type headache, or cluster headache 2. However, in older adults, secondary headache disorders due to underlying conditions like subarachnoid hemorrhage, stroke, or meningitis must be considered.
- Red Flags: Certain "red flags" in the history and physical examination can indicate a secondary headache disorder, including sudden-onset headache, headache with fever, confusion, or neck stiffness 3.
- Laboratory Tests: While there are no specific laboratory tests for primary headache disorders, tests may be ordered to rule out secondary causes. These may include:
- Complete Blood Count (CBC) to evaluate for infection or inflammation
- Blood chemistry tests to evaluate for electrolyte imbalances or renal function
- Erythrocyte Sedimentation Rate (ESR) or C-reactive protein (CRP) to evaluate for giant cell arteritis in patients over 50 years old
- Lumbar puncture (LP) if subarachnoid hemorrhage or meningitis is suspected
- Imaging Studies: Neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) may be considered in patients with red flags, abnormal neurological examination, or if the headache is sudden-onset and severe 3.
- Clinical Judgment: The decision to order laboratory tests or imaging studies should be based on clinical judgment and the presence of red flags or abnormal findings on physical examination. Established guidelines may not always be followed in clinical practice 4.
In the case of a 97-year-old patient with headache, a thorough history and physical examination are essential to guide the diagnostic workup. Laboratory tests and imaging studies should be ordered based on the presence of red flags or abnormal findings, rather than as a routine part of the evaluation 3, 4.