What is a safe medication to treat daily non-migraine headaches in a 74-year-old female with a normal computed tomography (CT) head scan?

Safe Medication for Daily Non-Migraine Headaches in a 74-Year-Old Female

For daily non-migraine headaches in a 74-year-old female with normal CT scan, acetaminophen is the safest first-line medication due to its favorable safety profile in older adults. 1, 2

First-Line Treatment Options

• Acetaminophen (650-1000mg) is recommended as the safest initial treatment for older adults with chronic daily headaches due to minimal drug interactions and favorable safety profile 2, 3
• Regular dosing schedule (up to 3000mg daily divided doses) is more effective than as-needed dosing for chronic daily headaches 3
• Acetaminophen has demonstrated efficacy for headache relief with an excellent safety profile, particularly important in elderly patients 3

Second-Line Treatment Options

• NSAIDs may be considered if acetaminophen is ineffective, but should be used with caution due to increased risk of gastrointestinal, renal, and cardiovascular adverse effects in elderly patients 4, 5
• If using NSAIDs, consider lower doses and shorter duration of treatment with close monitoring for adverse effects 4, 6
• Combination analgesics containing caffeine (such as acetaminophen plus caffeine) may be more effective than acetaminophen alone but carry risk of medication overuse headache 4, 5

Important Considerations for Elderly Patients

• Avoid opioid analgesics (including tramadol) for chronic daily headaches due to high risk of dependency, rebound headaches, and loss of efficacy 4, 7
• In patients over 75 years, medication doses should generally start at the lower end of dosing range due to decreased hepatic, renal, or cardiac function 7
• Medication overuse headache is a significant concern when treating chronic daily headaches; limit acute treatments to no more than twice weekly 4, 6

Monitoring and Follow-Up

• Evaluate treatment response within 2-3 months after initiation or change in treatment 4
• Use headache calendars to track frequency, severity, and medication use 4
• Consider preventive therapy if acute medications are needed more than twice weekly 4

Special Cautions

• Triptans and ergot derivatives are generally not first-line for non-migraine headaches and carry contraindications in patients with cardiovascular disease 6
• Butalbital-containing compounds should be avoided due to risk of dependency and rebound headaches 4
• Sedatives are no longer widely recommended for headache management in elderly patients 4

Treatment Algorithm

1. Start with acetaminophen 650-1000mg every 6 hours as needed (not exceeding 3000mg/day) 1, 3
2. If inadequate response after 2-3 trials, consider adding caffeine or switching to a low-dose NSAID with gastroprotection 4, 5
3. If headaches persist, consider evaluation for preventive therapy rather than increasing acute medication use 4
4. For all patients with chronic daily headaches, investigate potential triggers including stress, sleep disturbances, and dietary factors 4