What tests are recommended for a 60-year-old patient with new onset migraines?

Recommended Tests for a 60-Year-Old with New-Onset Migraines

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, with MRI of the brain as the preferred initial test. 1

Immediate Neuroimaging

• MRI of the brain (with and without contrast) is the first-line test for new-onset headache in a 60-year-old without contraindications, as it is superior to CT for detecting tumors, stroke, and structural lesions. 1, 2

• Neuroimaging takes priority over laboratory testing in this age group, as the American College of Radiology identifies new-onset headache in older adults as an indication for aggressive workup. 1

• CT of the head (non-contrast) should only be used if thunderclap headache is present, recent trauma occurred, or MRI is contraindicated or unavailable. 1

• The yield of neuroimaging in older adults with new-onset headache is significantly higher than in younger patients, with up to 15% having serious pathology such as stroke, temporal arteritis, neoplasm, or subdural hematoma. 3

Essential Laboratory Tests

• ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) must be checked in all patients over 50 with new headache to exclude temporal arteritis and prevent permanent vision loss. 1, 4

• Basic metabolic panel to check glucose and sodium levels, as abnormalities can cause headache. 1

• Complete blood count (CBC) to evaluate for anemia or other hematologic abnormalities. 2

• Thyroid function tests (TSH, free T4) if clinical suspicion exists, as thyroid disorders can present with headache. 2

Focused Neurologic Examination

• Perform a thorough neurologic examination, as any abnormal finding mandates immediate imaging and is more revealing than laboratory studies in this age group. 1

• Look specifically for focal neurologic deficits, papilledema on fundoscopic examination, impaired memory, or personality changes—all red flags for secondary causes. 5, 6, 7

• Check for neck stiffness or meningeal signs if infection is suspected. 7

When to Consider Lumbar Puncture

• Lumbar puncture is indicated if CT is negative but thunderclap headache occurred, suspicion for meningitis or encephalitis exists, or high/low CSF pressure syndromes are suspected. 1

• Perform LP >6 hours from symptom onset for xanthochromia evaluation if subarachnoid hemorrhage is suspected. 1

• Xanthochromia detected by spectrophotometry remains 100% sensitive for subarachnoid hemorrhage up to 2 weeks after the event. 3

Critical Red Flags Requiring Emergent Evaluation

• Thunderclap headache (sudden, severe onset). 5, 6, 8

• Headache worsened by Valsalva maneuver or cough. 6, 8

• Headache awakening patient from sleep. 5, 8

• Progressively worsening pattern. 2, 8

• Neurologic deficits or impaired consciousness. 8, 7

• Fever with headache. 5, 8

Important Clinical Pitfalls

• Do not assume primary headache disorder in this age group—migraine often remits with older age while the incidence of secondary headaches increases, so onset of apparent migraine after age 50 should arouse suspicion of an underlying cause. 5, 1

• Do not skip temporal arteritis workup, as the ESR can be normal in 10% to 36% of patients with temporal arteritis, and superficial temporal artery biopsy may be needed if clinical suspicion remains high despite normal labs. 3

• Do not start daily analgesics without establishing diagnosis, as this can lead to medication overuse headache. 1

• Neuroimaging can reveal clinically insignificant abnormalities (white matter lesions, arachnoid cysts, meningiomas) that may alarm the patient and lead to unnecessary further testing, so counsel patients appropriately. 5

When Neuroimaging is NOT Needed

• Primary headache disorders without red flags or abnormal examination findings do not need neuroimaging. 8

• However, given the patient's age of 60 years, the threshold for imaging should be very low, as this itself is a red flag. 1, 6