What is the recommended head imaging and management for a 59-year-old patient with increased headaches after a fall and hitting their head?

Head Imaging for 59-Year-Old with Post-Fall Headaches

A noncontrast head CT is indicated for this 59-year-old patient with increased headaches following head trauma, as the patient meets multiple criteria from established clinical decision rules: age >60 years threshold (close proximity at 59), presence of headache, and physical evidence of head trauma. 1

Imaging Recommendation

Obtain a noncontrast head CT immediately. This patient satisfies the American College of Emergency Physicians (ACEP) Level A recommendation criteria, which mandates CT imaging in head trauma patients when headache is present, particularly given the patient's age approaching the 60-year threshold. 1

Supporting Clinical Decision Rules

The patient meets criteria across multiple validated decision rules:

• New Orleans Criteria: Headache alone is sufficient indication for CT imaging in patients with head trauma, with 97.7%-99.4% sensitivity for traumatic findings. 1

• Canadian CT Head Rule: While designed for higher specificity, this patient's age (59, approaching 65) combined with headache symptoms warrants imaging consideration. 1

• ACEP Clinical Policy (Level A): Explicitly recommends noncontrast head CT for head trauma patients with headache, especially when age >60 years (this patient is 59). 1

Critical Assessment Points

Before imaging, document the following to guide management:

• Loss of consciousness or post-traumatic amnesia: Presence elevates risk significantly and strengthens imaging indication. 1

• Vomiting episodes: ≥2 episodes is a high-risk feature requiring immediate CT. 2

• Glasgow Coma Scale score: Any score <15 mandates immediate imaging. 1, 2

• Coagulopathy status: Antiplatelet agents (aspirin, clopidogrel) or anticoagulants (warfarin) dramatically increase intracranial hemorrhage risk and make CT mandatory regardless of other factors. 1

• Focal neurological deficits: Any abnormal neurological findings require immediate imaging. 1, 2

• Mechanism of injury: Falls from >3 feet or 5 stairs are considered dangerous mechanisms. 1, 2

Why CT Over Other Modalities

Noncontrast CT is the only appropriate initial imaging modality for acute head trauma. 1

• MRI, CTA, MRA, skull radiographs, and PET have no role in initial acute head trauma evaluation. 1

• CT has revolutionized acute head trauma management since the 1970s with proven value in detecting neurosurgical lesions (hemorrhage, herniation, hydrocephalus). 1

• CT sensitivity for acute subarachnoid hemorrhage is 91% (95% CI: 82%-97%) when performed acutely. 3

Common Pitfalls to Avoid

Do not delay imaging based on "mild" symptom characterization. The term "increased headaches" suggests progressive symptoms, which is a red flag requiring immediate evaluation rather than observation. 4

Do not assume age 59 is "safe" because it falls just below the 60-year threshold. The age cutoffs (>60 or ≥65 depending on the rule) represent statistical thresholds, not absolute boundaries. Clinical judgment should err toward imaging in borderline cases. 1

Do not substitute clinical observation for imaging when clear criteria are met. Both the New Orleans Criteria and ACEP guidelines are designed to achieve near 100% sensitivity for neurosurgical intervention, which requires liberal imaging. 1

Post-Imaging Management

If CT is negative but headaches persist or worsen:

• Monitor for red flag symptoms: Progressive worsening, new focal deficits, altered mental status, severe refractory pain, or orthostatic features warrant repeat neuroimaging (MRI preferred over repeat CT). 4

• Acute pain management: NSAIDs or acetaminophen for mild-moderate pain, limiting use to <15 days/month to prevent medication overuse headache. 4

• Reassessment timeline: Schedule follow-up within 2-4 weeks to evaluate progression with headache diary tracking frequency, severity, and medication use. 4

• Consider prophylactic therapy: If headaches persist beyond 4-6 weeks and occur ≥15 days per month, topiramate is first-line prophylaxis for chronic post-traumatic headache. 4

Repeat neuroimaging (MRI preferred) is indicated if: headaches progressively worsen despite appropriate management, new neurological findings emerge, headache pattern changes significantly, or severe refractory headache develops. 4