Differential Diagnosis for Headache in a 60-year-old
Single most likely diagnosis
- Tension headache: This is the most common type of headache in adults, characterized by a dull, aching sensation on both sides of the head, often accompanied by muscle tension in the neck and scalp. Its prevalence and the fact that it can occur at any age, including 60, make it a likely candidate.
Other Likely diagnoses
- Migraine: Although migraines are more common in younger populations, they can persist into older age or even start for the first time in individuals over 60. They are characterized by severe, unilateral headaches often accompanied by nausea, vomiting, and sensitivity to light and sound.
- Cervicogenic headache: These headaches are referred from the cervical spine and are more common in older adults due to degenerative changes in the neck. They are typically unilateral and can be accompanied by neck pain and limited range of motion.
- Medication overuse headache: Given the higher likelihood of chronic medication use in older adults for various conditions, medication overuse headache is a consideration. It occurs when frequent or excessive use of headache medications leads to worsening headache frequency or intensity.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Subarachnoid hemorrhage: Although less common, this condition is life-threatening and requires immediate medical attention. It typically presents with a sudden, severe headache (often described as "the worst headache of my life") and can be accompanied by vomiting, altered consciousness, and sometimes neck stiffness.
- Temporal arteritis (Giant Cell Arteritis): This condition is more common in individuals over 50 and can lead to blindness if not treated promptly. It presents with unilateral headache, scalp tenderness, jaw claudication, and visual disturbances.
- Brain tumor: While rare, brain tumors can cause headaches, especially if they increase intracranial pressure. The headache is typically worse in the morning and can be accompanied by nausea, vomiting, and neurological deficits.
- Stroke or Transient Ischemic Attack (TIA): Headache can be a feature of stroke or TIA, especially if there is associated hypertension or hemorrhage. Immediate recognition and treatment are crucial to prevent further brain damage.
Rare diagnoses
- Trigeminal neuralgia: This condition involves sudden, severe, shock-like pain around the eyes, lips, or nose, typically on one side of the face. It's more common in older adults but is relatively rare compared to other headache causes.
- Occipital neuralgia: Involves pain in the distribution of the occipital nerves, which can mimic other headache types but is less common.
- Hypnic headache: A rare headache disorder that occurs exclusively during sleep, typically in individuals over 60, and can be very distressing.
Each of these diagnoses has distinct features that can guide a more detailed history and physical examination to narrow down the differential diagnosis and lead to appropriate management.