What are the treatment options for a 71-year-old female with constant dull headaches?

Treatment Options for Constant Dull Headaches in a 71-Year-Old Female

For a 71-year-old female with constant dull headaches, first-line treatment should include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-600mg) or naproxen sodium (500-550mg), with careful monitoring for secondary causes of headache which are more common in older adults. 1

Initial Assessment Considerations

When evaluating headaches in an elderly patient, it's crucial to:

• Rule out serious underlying causes, as the risk of secondary headache increases with age 2, 3
• Consider that new-onset headache after age 50 should raise suspicion for an underlying cause 2
• Screen for red flags including:
  • Sudden onset headache
  • Neurological deficits
  • History of cancer or immunosuppression
  • Headaches provoked by physical activity or postural changes 4

Treatment Algorithm

First-Line Treatments

• NSAIDs (if no contraindications):
  • Ibuprofen 400-600mg
  • Naproxen sodium 500-550mg 1
• Acetaminophen (safer option if NSAIDs are contraindicated)

Second-Line Treatments

If first-line treatments are ineffective after 2-3 trials:

• Amitriptyline 10-100mg oral at night (beneficial for both headache prevention and sleep)
  • Caution: Monitor for anticholinergic effects, especially in elderly patients 2, 1
• Flunarizine 5-10mg once daily
  • Caution: Avoid in patients with parkinsonism or depression 2

Third-Line Treatments

For refractory cases:

• OnabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks 2
• CGRP monoclonal antibodies (erenumab, fremanezumab, eptinezumab) 2, 1
  • Note: These are typically reserved for cases that have failed other treatments

Non-Pharmacological Approaches

Particularly valuable for elderly patients to minimize medication burden:

• Regular aerobic exercise or strength training
• Maintaining a regular sleep schedule
• Adequate hydration
• Identification and avoidance of triggers
• Relaxation techniques or mindfulness 1
• Acupuncture may provide benefit 2, 1

Special Considerations for Elderly Patients

1. Medication safety:

   • Avoid triptans if cardiovascular risk factors are present 1
   • Use lower starting doses of medications and titrate slowly
   • Monitor for drug interactions with existing medications

2. Follow-up monitoring:

   • Evaluate treatment response within 2-3 months of initiation 2
   • Use headache calendars to track frequency, severity, and medication use 2, 1
   • Assess for adverse effects at each visit

3. Medication overuse:

   • Limit acute medications to prevent medication overuse headache:
     • NSAIDs: no more than 15 days/month
     • OTC medications: no more than 14 days/month 1

Pitfalls to Avoid

• Assuming headaches in elderly patients are always benign - secondary causes are more common in this age group 3, 5
• Missing temporal arteritis, which requires urgent treatment to prevent vision loss
• Overlooking medication overuse as a cause of persistent headaches
• Using triptans in patients with cardiovascular disease or risk factors 1
• Failing to reassess diagnosis if treatment is ineffective

Remember that constant dull headaches in an elderly patient warrant thorough evaluation, and treatment should be initiated with careful consideration of comorbidities and potential medication interactions.