What labs and imaging are recommended for a 62-year-old female with new onset migraines?

New-Onset Migraine in a 62-Year-Old Female: Diagnostic Workup

Neuroimaging with MRI is the priority investigation for this patient, as new-onset headache after age 50 is a recognized red flag requiring exclusion of serious intracranial pathology before considering primary migraine. 1, 2

Critical Age-Related Considerations

This patient's age is the most important factor driving the diagnostic approach:

• New-onset headache after age 50 substantially increases the likelihood of secondary causes including tumor, stroke, subdural hematoma, temporal arteritis, and other structural lesions 1, 3
• Up to 15% of patients aged 65 and older presenting with new-onset headaches have serious pathology requiring specific treatment 3
• The American College of Radiology specifically designates new-onset headache in older adults as an indication for neuroimaging, prioritizing it over laboratory testing 1

Imaging Recommendations

Obtain MRI brain without delay as the preferred imaging modality:

• MRI is superior to CT for detecting structural lesions, offering higher resolution without ionizing radiation exposure 4
• MRI should be obtained to exclude tumor, stroke, subdural hematoma, or other structural abnormalities 1
• CT may be substituted only if MRI is unavailable or contraindicated, though it is less sensitive 4

Common pitfall: Do not delay imaging while awaiting laboratory results in this age group—the history and neurologic examination combined with imaging are more revealing than laboratory studies 1

Laboratory Testing

While imaging takes priority, obtain basic laboratory studies concurrently:

• Basic metabolic panel including serum glucose and sodium, as hypoglycemia, hyperglycemia, and hyponatremia can cause headache 1
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to screen for temporal arteritis, which affects 60-90% of patients with this condition through headache as the presenting symptom 3

Important caveat: ESR can be normal in 10-36% of patients with temporal arteritis, so clinical suspicion should drive further evaluation including temporal artery biopsy if indicated 3

Essential Clinical Assessment Before Imaging

Perform a focused neurologic examination and assess for specific red flags:

• Abnormal neurologic findings on examination mandate immediate imaging 4, 2
• Headache characteristics requiring urgent investigation include: thunderclap onset, progressive worsening, awakening from sleep, or worsening with Valsalva maneuver 4, 2
• Associated symptoms such as fever, focal neurological deficits, impaired memory, or visual changes suggest secondary causes 4

When Imaging Can Be Deferred

Only if the neurologic examination is completely normal AND the headache meets strict International Headache Society criteria for migraine without atypical features should you consider deferring imaging 4. However, given this patient's age, the conservative and recommended approach is to obtain neuroimaging regardless 1, 2.

Diagnostic Yield Context

Understanding the probability of findings helps frame patient discussions:

• In patients with normal neurologic examinations and chronic headache, the yield of significant abnormalities is low (0.2-0.5% for migraine specifically) 4
• However, age over 50 fundamentally changes this calculus, making imaging medically indicated rather than optional 1, 3
• MRI may reveal clinically insignificant findings (white matter lesions, arachnoid cysts, small meningiomas) that require careful interpretation to avoid unnecessary alarm 4