What should be done for a 79-year-old patient with a severe headache and dizziness?

Emergency Department Evaluation is Urgently Indicated

A 79-year-old patient with severe headache for 3 days and dizziness should go to the emergency room immediately for urgent evaluation. This presentation contains multiple red flags that warrant immediate medical assessment, including new-onset severe headache in an older adult, prolonged duration, and associated neurological symptoms.

Critical Red Flags Present

This patient exhibits several concerning features that mandate urgent evaluation:

• New headache in elderly patient (>50 years) - This is a well-established red flag requiring immediate neuroimaging consideration 1, 2
• Severe, persistent headache lasting 3 days - Prolonged duration with severity suggests potential serious underlying pathology 2
• Associated dizziness - Neurological symptoms accompanying headache increase concern for cerebrovascular events, including stroke or cerebral venous thrombosis 1, 3
• Age 79 years - Older adults presenting with these symptoms have higher rates of serious pathology and require more intensive evaluation 4, 5

Immediate Emergency Department Evaluation Required

Initial Assessment Priorities

The ED evaluation should focus on excluding life-threatening causes:

• Neuroimaging with MRI (preferred) or CT - Brain MRI with and without contrast is recommended to evaluate for structural abnormalities, signs of increased intracranial pressure, stroke, hemorrhage, and secondary causes of headache 3, 2
• MR venography (MRV) - Should be considered to rule out cerebral venous thrombosis, which can present with persistent headache and dizziness 1, 3
• Vital signs with blood pressure monitoring - Severe hypertension can cause headache and dizziness, and hypertensive emergency (BP >180/110 mmHg) requires immediate intervention 3, 6
• Complete neurological examination - Focus on mental status, cranial nerve function, motor/sensory deficits, and fundoscopic examination for papilledema 2

Laboratory Testing in ED

Essential blood work includes:

• ESR and CRP - To evaluate for giant cell arteritis (temporal arteritis), which is critical in patients over 50 with new headache, especially if scalp tenderness or jaw claudication present 1, 2
• Complete blood count and metabolic panel - To assess for infection, anemia, electrolyte abnormalities, and renal function 3
• Glucose and hemoglobin A1c - If vasculopathic etiology suspected 1, 2

Specific Concerns in This Age Group

Cerebrovascular Events

Older adults with headache and dizziness are at increased risk for:

• Stroke or transient ischemic attack - Cerebral hemorrhage, subarachnoid hemorrhage, and ischemic stroke can present with severe headache and dizziness 7
• Cerebral venous thrombosis - Can present with persistent headache and neurological symptoms, requiring prompt diagnosis 1, 3

Giant Cell Arteritis

This is a critical consideration in patients over 50:

• Temporal artery evaluation - Check for scalp tenderness, jaw claudication, or temporal artery abnormalities 1, 2
• Immediate treatment if suspected - High-dose corticosteroids should be initiated immediately if giant cell arteritis suspected, even before biopsy confirmation 2

Increased Intracranial Pressure

Signs requiring immediate attention include:

• Papilledema on fundoscopic exam - Indicates elevated intracranial pressure 1
• Progressive worsening - Headache that progressively worsens over days suggests space-occupying lesion or other serious pathology 1, 2

Why Outpatient Management is Inappropriate

Do not attempt outpatient management or delay ED evaluation for the following reasons:

• Older adults (especially >75 years) presenting to ED with neurological symptoms have high rates of appropriate urgent/emergent conditions requiring immediate intervention 4, 5
• The combination of severe headache, dizziness, and advanced age represents high-risk features that cannot be adequately evaluated in outpatient settings 2
• Time-sensitive conditions like stroke, cerebral venous thrombosis, and giant cell arteritis require immediate diagnosis and treatment to prevent permanent neurological damage or death 1, 2, 7
• Older adults have increased complexity and higher hospitalization rates when presenting with these symptoms 5

Common Pitfalls to Avoid

• Do not assume this is migraine - While migraine can occur in older adults, new-onset headache after age 50 requires exclusion of secondary causes first 1, 2
• Do not prescribe triptans without evaluation - Triptans are contraindicated in patients with cerebrovascular disease, uncontrolled hypertension, and multiple cardiovascular risk factors common in this age group 1, 7
• Do not delay for outpatient imaging - Urgent neuroimaging in ED setting is required, not scheduled outpatient studies 3, 2