From the Guidelines
For elderly patients with headaches after a traumatic head injury, treatment should begin with acetaminophen (Tylenol) at 500-1000mg every 6 hours as needed, not exceeding 3000mg daily, as it is preferred over NSAIDs like ibuprofen due to lower bleeding risk, which is particularly important after head trauma 1. This approach prioritizes minimizing the risk of bleeding complications, which is crucial in the elderly population, especially after a head injury.
- The use of acetaminophen is recommended as the first-line treatment for headache in the elderly following a traumatic head injury due to its safety profile and efficacy in pain management.
- If acetaminophen is insufficient, consulting a healthcare provider about adding a low-dose NSAID or using tramadol 25-50mg every 6 hours for short-term use may be considered, weighing the benefits against the potential risks, especially in patients with a history of bleeding or on anticoagulant therapy.
- Additionally, non-pharmacological interventions such as rest in a quiet, dark room, cold compresses, adequate hydration, and gentle resumption of activities as tolerated can provide additional relief and support recovery.
- It is essential to evaluate any elderly patient with a head injury promptly for serious conditions like subdural hematoma, especially if they take blood thinners, and to monitor for warning signs that require immediate medical attention, including worsening headache, confusion, vomiting, seizures, weakness, or vision changes.
- Given the high risk of complications in elderly trauma patients due to preexisting medical conditions, frailty, and poor physiological reserve, as highlighted in the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1, a comprehensive and cautious approach to their care is necessary.
From the Research
Treatment Options for Headache in the Elderly Following a Traumatic Head Injury (THI)
- The treatment of headache in the elderly following a THI is crucial, as headaches can be a signature of a disease that leads to serious morbidity and mortality 2.
- Primary headaches, such as migraine, tension-type, and trigeminal autonomic cephalalgias, can be treated with various medications, including carbamazepine, baclofen, and indomethacin 2, 3.
- Secondary headaches, which are more common in the elderly, require a thorough evaluation to rule out serious underlying causes, such as tumor, subdural hematoma, stroke, and temporal arteritis 3, 4.
- Imaging and laboratory evaluations, including head CT and brain MRI, are indicated in the presence of "red flag" signs or symptoms, such as sudden onset of headache, increased frequency or severity of headache, and focal neurologic signs or symptoms 3, 5.
- Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance 3.
Evaluation and Diagnosis
- A detailed headache history and thorough neurologic examination are essential to distinguish among primary and secondary headache disorders 3, 5.
- "Red flags" for secondary disorders, such as sudden onset of headache, onset of headache after 50 years of age, and increased frequency or severity of headache, warrant further evaluation and imaging studies 5.
- Noncontrast computed tomographic (CT) scanning and lumbar puncture may be necessary to rule out intracranial pathology, while magnetic resonance imaging (MRI) can provide more detail and is necessary for imaging the posterior fossa 5.