What is the next best step in managing a patient over 50 presenting with a new chronic headache?

Management of New Chronic Headache in Patients Over 50

In a patient over 50 presenting with new chronic headache, the next best step is to perform a thorough evaluation for secondary causes, including neuroimaging with non-contrast head CT or brain MRI, as new-onset headache after age 50 should arouse suspicion of an underlying serious pathology rather than primary headache disorder. 1, 2, 3

Critical Red Flag Assessment

The priority in this age group is excluding life-threatening secondary causes before considering primary headache disorders:

• Evaluate for "thunderclap" or sudden-onset headache, which may indicate subarachnoid hemorrhage 4, 2
• Assess for headache worsening when lying down or with Valsalva maneuver, suggesting increased intracranial pressure 4, 2
• Check for neurological deficits (weakness, sensory changes, visual disturbances), which may indicate stroke, hemorrhage, or mass lesion 4, 2
• Determine if headache awakens patient from sleep or is progressively worsening, both concerning features in this age group 2
• Assess for temporal artery tenderness or jaw claudication, as temporal arteritis is a critical diagnosis in patients over 50 3, 5

Why Age Over 50 Changes the Approach

Migraine often remits with older age, whereas the incidence of many secondary headaches increases substantially. 1 The guideline explicitly states that "onset of apparent migraine after the age of 50 years should, therefore, arouse suspicion of an underlying cause." 1

Studies show that up to 15% of patients aged 65 and over presenting with new-onset headaches may have serious pathology including stroke, temporal arteritis, neoplasm, and subdural hematoma. 5

Neuroimaging Indications

Neuroimaging should be strongly considered in this population:

• Non-contrast head CT is the first-line imaging study in the acute/emergency setting 4, 2
• Brain MRI with and without contrast is preferred when available, particularly for persistent headache, as it provides superior detection of masses, ischemia, and other structural abnormalities 4
• The threshold for neuroimaging should be lower in patients over 50 with new headache, even without classic red flags 2, 5

The yield of neuroimaging in older patients with new headache is significantly higher than in younger populations with chronic primary headaches. 5

Essential Laboratory Evaluation

If temporal arteritis is suspected (critical in this age group):

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be obtained, though ESR can be normal in 10-36% of patients with temporal arteritis 5
• Temporal artery biopsy may be necessary for definitive diagnosis, as false-negative results occur in 5-44% of cases 5

Additional laboratory studies to consider:

• Complete blood count to evaluate for infection, anemia, or thrombocytopenia 4
• Basic metabolic panel for electrolyte abnormalities 4
• Coagulation studies if bleeding disorder suspected 4

Common Pitfalls in This Population

Secondary headache, comorbidities, and adverse events are all more likely in older people. 1 Critical mistakes to avoid:

• Do not assume primary headache disorder without thorough evaluation for secondary causes 1, 3
• Do not overlook medication overuse headache, as older patients often take multiple medications 6, 7
• Be cautious with triptan use due to higher likelihood of cardiovascular disease and risk factors, though no robust evidence supports increased cardiovascular events from triptans per se 1
• Consider drug interactions and adverse effects more carefully, as older patients are more susceptible to medication side effects 1

If Secondary Causes Are Excluded

Only after ruling out secondary causes should chronic migraine be considered:

• Chronic migraine requires ≥15 headache days per month for >3 months, with ≥8 days meeting migraine criteria 2, 6
• Poor evidence base exists for all migraine drugs in older age groups, requiring careful medication selection 1
• Monitor blood pressure regularly if triptans are used, with periodic cardiovascular risk assessment 1

Referral Considerations

Specialist referral is indicated for:

• Patients with chronic migraine after initial evaluation 1
• Headache of uncertain diagnosis 7
• Poor response to initial management strategies 7
• Any concerning features suggesting secondary pathology 2, 7