What is the evaluation and management approach for new headaches in a 68-year-old patient?

New Headache in a 68-Year-Old: Evaluation and Management

New-onset headache after age 50 is a red flag requiring immediate neuroimaging to exclude life-threatening secondary causes such as tumor, stroke, subdural hematoma, or temporal arteritis. 1, 2

Immediate Risk Stratification

Age 68 automatically places this patient in a high-risk category that mandates aggressive workup. 3, 1, 2 The American College of Radiology specifically identifies new-onset headache in older adults as an indication for neuroimaging, prioritizing it over laboratory testing. 2

Critical Red Flags to Assess

Determine if any of the following are present, as they indicate emergent evaluation: 1, 4

• Thunderclap headache (sudden, severe onset reaching maximum intensity within 1 hour) 3
• Neurologic deficits on examination 1, 2
• Headache worsened by Valsalva maneuver 1, 5
• Headache awakening patient from sleep 1, 5
• Progressively worsening pattern 1, 2
• Fever or meningeal signs 4
• Papilledema or impaired consciousness 4

Diagnostic Workup Algorithm

Step 1: Obtain Targeted History

Focus on specific high-yield elements rather than generic assessment: 1

• Onset characteristics: Sudden vs. gradual, time to peak intensity 3, 4
• Temporal pattern: Morning headaches suggest OSA or increased intracranial pressure 6
• Exertional triggers: Headache with cough, Valsalva, or physical activity 5, 7
• Medication history: Verify all over-the-counter analgesic use to assess for medication overuse headache 6
• Associated symptoms: Jaw claudication, visual changes, weight loss (temporal arteritis) 6

Step 2: Perform Focused Neurologic Examination

Any abnormal neurologic finding mandates immediate imaging. 1, 2 The neurologic examination is more revealing than laboratory studies in this age group. 2

Step 3: Order Neuroimaging First

MRI of the brain is the preferred initial test for new headache in a 68-year-old without contraindications. 2, 5 MRI is superior to CT for detecting tumors, stroke, and structural lesions. 2

Use non-contrast CT of the head only if:

• Thunderclap headache is present (to exclude subarachnoid hemorrhage) 3, 4
• Recent trauma occurred 5, 7
• MRI is contraindicated or unavailable 4

Step 4: Obtain Targeted Laboratory Tests

Essential labs for age 68 with new headache: 6, 2

• ESR and CRP: Mandatory to exclude temporal arteritis in patients over 50 6
• Basic metabolic panel: Check glucose and sodium, as abnormalities can cause headache 2

Step 5: Consider Lumbar Puncture

LP is indicated if: 3, 5

• CT is negative but thunderclap headache occurred (to detect xanthochromia from subarachnoid hemorrhage) 3
• Suspicion for meningitis or encephalitis exists 5
• High or low CSF pressure syndromes are suspected 5

Timing matters: LP should be performed >6 hours from symptom onset for xanthochromia evaluation. 3

Common Pitfalls to Avoid

Do not assume primary headache disorder in this age group. In patients with apparent late-onset migraine, suspect an underlying secondary cause. 3 Older adults have higher risks of secondary headache and comorbidities. 3

Do not start daily analgesics without establishing diagnosis. This can lead to medication overuse headache and worsen the problem. 6 The American Academy of Family Physicians specifically advises against this approach. 6

Do not skip temporal arteritis workup. ESR and CRP must be checked in all patients over 50 with new headache, as missing temporal arteritis can result in permanent vision loss. 6

Management After Diagnosis

If Imaging and Labs Are Normal

Consider specific secondary causes based on clinical features: 6

• Morning headaches resolving within hours: Evaluate for obstructive sleep apnea with sleep study referral 6
• Positional headaches: Consider CSF pressure abnormalities 6, 5
• Frequent analgesic use: Diagnose medication overuse headache and implement detoxification 3, 6

If Primary Headache Disorder Is Diagnosed

For acute migraine treatment in older adults: 3

• NSAIDs (ibuprofen, naproxen sodium) are first-line 3
• Triptans should not be used if uncontrolled hypertension or cardiac risk factors exist 3
• Consider higher risks of adverse events with older age 3

For migraine prevention (if ≥2 headaches per week): 3, 1

• First-line: Propranolol 80-240 mg/day, timolol 20-30 mg/day, or amitriptyline 30-150 mg/day 3
• Alternative: Divalproex sodium 500-1500 mg/day 3

Referral Indications

Refer to neurology or headache specialist for: 1

• Difficult-to-manage cases 1
• Atypical features despite negative workup 6
• Chronic daily headache (>15 days/month) requiring prophylactic therapy 6