Does a 50-year-old female with new onset daily headaches require imaging?

Neuroimaging for New Onset Daily Headaches in a 50-Year-Old Female

A 50-year-old female with new onset daily headaches requires neuroimaging due to the presence of significant red flags that suggest possible secondary headache disorder. 1, 2

Red Flags Requiring Imaging in This Case

• New headache onset after age 50 is a significant red flag that suggests possible secondary headache and warrants neuroimaging 1, 2
• Daily occurrence pattern of headaches increases suspicion for secondary causes 3
• The combination of both new onset and age ≥50 years substantially increases the risk of serious underlying pathology 1

Recommended Imaging Approach

• MRI is the preferred initial imaging modality due to its higher resolution and absence of radiation exposure 1, 2
• CT without contrast is an alternative when MRI is not readily available or when acute intracranial hemorrhage is suspected 1
• If thunderclap features are present (sudden onset reaching maximum intensity within seconds to minutes), immediate CT followed by lumbar puncture (if CT is negative) is indicated 1

Potential Secondary Causes to Consider

• Intracranial space-occupying lesions including tumors, which occur in approximately 0.8% of patients with headache and normal neurological examination 4
• Vascular pathologies such as arteriovenous malformations (0.2%), aneurysms (0.1%), or subdural hematomas (0.2%) 4
• Temporal arteritis should be considered in patients over 50 with new-onset headache 2, 4
• Intracranial hypotension or hypertension may present with new daily headaches 5

Additional Assessment Considerations

• Evaluate for other red flags during history taking:

  • Headache awakening patient from sleep 1, 2
  • Headache aggravated by Valsalva maneuver or position changes 1, 3
  • Progressive worsening of headache intensity 1, 2
  • Associated focal neurological symptoms or signs 1, 2
  • Systemic symptoms such as weight loss or fever 2

• Perform thorough neurological examination to identify:

  • Focal neurological deficits 1, 2
  • Papilledema or other signs of increased intracranial pressure 6
  • Neck stiffness that might suggest meningeal irritation 1, 2

Common Pitfalls to Avoid

• Dismissing new daily headaches in older adults as tension-type or migraine without appropriate imaging can lead to missed serious pathology 4
• Delaying imaging when red flags are present increases risk of adverse outcomes 2
• Focusing only on primary headache disorders without considering secondary causes in patients with new onset headaches after age 50 3, 4
• Overlooking temporal arteritis which can present with headache in up to 90% of cases and requires prompt diagnosis to prevent vision loss 4

Follow-up Considerations

• If initial imaging is negative but symptoms persist, consider:
  • Referral to neurology for further evaluation 6
  • Additional testing such as lumbar puncture if clinical suspicion remains high 7
  • Monitoring for evolution of symptoms or development of new neurological signs 3

The combination of new onset headaches and age ≥50 years represents a significant red flag that necessitates neuroimaging to rule out secondary causes, even with a normal neurological examination 1, 2, 4.