Treatment of Headaches in Elderly Patients
Start with NSAIDs (ibuprofen 400 mg or naproxen 500-825 mg) as first-line acute treatment for headaches in elderly patients, but only after ruling out red flag symptoms that require immediate neuroimaging and evaluation for secondary causes like giant cell arteritis. 1, 2, 3
Initial Red Flag Assessment (Must Be Done First)
Before treating any elderly patient with headache, screen for these red flags that mandate immediate workup:
- Thunderclap onset (sudden, severe headache reaching maximum intensity within seconds to minutes) 3
- New-onset headache after age 50 (12 times more likely to have serious underlying causes than younger adults) 3, 4, 5
- Progressive worsening over days to weeks 1, 3
- Awakening from sleep 1, 3
- Worsening with Valsalva maneuver (coughing, straining, bending) 1, 3
- Scalp tenderness, jaw claudication, or visual symptoms (suspect giant cell arteritis) 3
- Abnormal neurologic examination 1, 3
If any red flags present: Order ESR and CRP immediately to rule out giant cell arteritis, and obtain MRI with and without contrast (preferred over CT for non-acute presentations). 3, 6 Start high-dose corticosteroids immediately if giant cell arteritis is suspected, before biopsy confirmation, to prevent permanent vision loss. 3, 7
Acute Treatment Algorithm for Primary Headaches
Step 1: First-Line Therapy (Mild to Moderate Headache)
NSAIDs are the cornerstone of acute treatment in elderly patients. 1, 2, 4
- Ibuprofen 400 mg at headache onset 1, 2
- Naproxen 500-825 mg at onset (advantage of longer duration of action) 1, 2, 4
- Aspirin 500-1000 mg as alternative 2
- Add antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg) if nausea present 2, 4
Critical safety monitoring required: Check baseline renal function and monitor for GI bleeding risk, as NSAIDs are implicated in 23.5% of adverse drug reaction hospitalizations in older adults. 2 Avoid NSAIDs when creatinine clearance <30 mL/min. 2
Step 2: Escalation for Inadequate Response
If NSAIDs alone provide insufficient relief, add acetaminophen to the NSAID (combination therapy improves efficacy). 1
If combination NSAID + acetaminophen fails, add a triptan to the NSAID or acetaminophen. 1 Despite cardiovascular concerns, triptans can be used in elderly patients with regular blood pressure monitoring and periodic cardiovascular risk assessment. 4 However, avoid triptans in patients with established coronary artery disease, uncontrolled hypertension, or previous stroke. 8, 9
Step 3: Alternative Options When Standard Therapy Fails
If patient does not tolerate or has inadequate response to triptan + NSAID combination, consider:
- CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1
- Lasmiditan (5-HT1F agonist): Safe in patients with cardiovascular risk factors, use only after all other options exhausted 1, 9
Never use opioids or butalbital for acute episodic headache treatment—they cause dependency, rebound headaches, and cognitive impairment in elderly patients. 1, 4
Medication-Overuse Headache Prevention
Limit acute medications to no more than 2 days per week (or 8-10 days per month maximum). 1, 2, 4 NSAIDs used ≥15 days per month or triptans used ≥10 days per month cause medication-overuse headache. 1
If patient requires acute treatment more than twice weekly, initiate preventive therapy immediately. 1, 2, 4
Preventive Therapy (When Headaches Occur ≥2 Days Per Month)
First-Line Preventive Options:
Beta-blockers (start low, titrate slowly): 2, 3, 4
- Metoprolol, propranolol, atenolol, or bisoprolol
- Monitor for bradycardia, hypotension, worsening heart failure, COPD exacerbation, and depression
Topiramate (strong evidence from RCTs): 2, 3, 4
- Start 25 mg daily, titrate slowly
- Monitor for cognitive side effects, kidney stones, weight loss
Candesartan (alternative when beta-blockers contraindicated): 4
Allow 2-3 months trial period before concluding treatment failure for oral preventive medications. 4
Critical Pitfalls to Avoid
- Never dismiss new-onset headache after age 50 as benign without thorough evaluation for secondary causes (stroke, temporal arteritis, mass lesions). 3, 4, 7
- Never allow acute medication use more than twice weekly without initiating preventive therapy. 1, 2, 4
- Never combine NSAIDs with anticoagulants (warfarin or DOACs) without careful monitoring—significantly increases bleeding risk. 2
- Never use immediate-release nifedipine for headache in elderly—increases risk of hypotension and falls. 2
- Never start with high doses—elderly patients have altered drug metabolism; start low and titrate slowly. 3, 4, 8
- Never use tramadol routinely—reserve only for when NSAIDs absolutely contraindicated, starting at 12.5-25 mg every 4-6 hours. 2