What is the appropriate workup for headache in an elderly patient?

Headache Workup for Elderly Patients

The workup for headache in elderly patients must prioritize ruling out secondary causes, as new-onset headache after age 50 should arouse suspicion of an underlying cause, with neuroimaging recommended for all elderly patients with new headache presentations. 1, 2

Red Flags Requiring Immediate Attention

• Sudden onset ("thunderclap") headache 1
• New headache after age 50 1, 2
• Progressively worsening headache 1
• Headache awakening patient from sleep 1
• Headache worsened by Valsalva maneuver 1
• Scalp tenderness, jaw claudication, or pain (suspect giant cell arteritis) 3
• Abnormal neurological examination findings 1
• Fever or signs of infection 3
• Papilledema or signs of increased intracranial pressure 3

Initial Assessment

• Conduct thorough history focusing on:

  • Onset, duration, frequency, and location of headache 1
  • Pain characteristics (quality, severity) 1
  • Associated symptoms (nausea, visual disturbances) 1
  • Aggravating and relieving factors 1
  • Medication use (risk of medication overuse headache) 1, 4

• Perform complete neurological examination with emphasis on:

  • Mental status 3
  • Cranial nerve function 3
  • Motor and sensory function 3
  • Fundoscopic examination for papilledema 3
  • Blood pressure measurement 3

Diagnostic Testing

Laboratory Studies

• Complete blood count 4
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to rule out giant cell arteritis 3, 2
• Basic metabolic panel 4
• Hemoglobin A1c and serum glucose (if suspecting vasculopathic etiology) 3
• Consider Lyme and syphilis testing if meningeal signs present 3

Neuroimaging

• MRI with and without contrast is preferred for most cases 3, 1
• CT scan may be used for acute presentations or when MRI is contraindicated 4
• Neuroimaging is indicated for:
  • All new-onset headaches in elderly patients 2
  • Headaches with abnormal neurological examination 1
  • Headaches worsened by Valsalva maneuver 1
  • Headaches that awaken patient from sleep 1
  • Progressively worsening headaches 1

Additional Testing (Based on Clinical Suspicion)

• Temporal artery biopsy if giant cell arteritis is suspected 3
• Lumbar puncture if meningitis, subarachnoid hemorrhage, or increased intracranial pressure is suspected 3
• Ophthalmologic evaluation if visual symptoms are present 3

Management Approach

For Primary Headaches (After Secondary Causes Ruled Out)

• For migraine:

  • First-line acute treatment: NSAIDs (ibuprofen, naproxen) 5
  • Use caution with triptans in elderly due to cardiovascular risk factors 3
  • First-line preventive options:
    • Beta-blockers (atenolol, metoprolol, propranolol) 3
    • Topiramate 3
    • Candesartan 3
  • Second-line preventive options:
    • Amitriptyline (use with caution due to anticholinergic effects) 3
    • Flunarizine 3

• For tension-type headache:

  • NSAIDs 5
  • Consider physical therapy 6

For Secondary Headaches

• Giant cell arteritis:

  • Immediate high-dose corticosteroids 3
  • Temporal artery biopsy 3

• Medication overuse headache:

  • Detoxification from overused medications 1
  • Implementation of appropriate preventive therapy 1

Special Considerations for Elderly Patients

• Consider comorbidities and potential drug interactions 3, 4
• Start with lower medication doses and titrate slowly 5
• Monitor blood pressure regularly if using triptans 3
• Avoid sodium valproate in women 3
• Be aware that clinical presentation of headaches may differ from younger patients 4, 6
• Higher risk of secondary causes necessitates more thorough evaluation 2

Follow-up Recommendations

• Evaluate treatment response within 2-3 months 5
• Use headache calendars to track frequency, severity, and medication use 5
• Consider referral to neurologist or headache specialist for:
  • Difficult-to-manage cases 1
  • Uncertain diagnosis 2
  • Poor response to initial treatment 5