What is the appropriate management for an elderly male with a 1-month history of constant retroorbital (behind the eyes) headaches that subside at night, without accompanying dizziness or nausea?

Urgent Evaluation for Giant Cell Arteritis and Secondary Causes Required

This elderly male with new-onset retroorbital headache after age 50 requires immediate workup for giant cell arteritis (GCA) and other secondary causes before considering primary headache management. The constant nature, age of onset, and duration are red flags that mandate investigation rather than empirical treatment 1.

Critical Red Flags Present

This patient has multiple concerning features:

• New headache after age 50 is a major red flag requiring immediate attention 1, 2
• Constant daily headache for 1 month represents a progressive pattern that warrants investigation 1
• Retroorbital location can be consistent with GCA, which presents with headache in 60-90% of cases 3

The absence of nausea and dizziness does not exclude serious pathology—these features are more typical of migraine, which this presentation does not suggest 4.

Immediate Diagnostic Workup Required

Laboratory Testing

• ESR and CRP must be obtained immediately to rule out giant cell arteritis 1
• Note that ESR can be normal in 10-36% of patients with GCA, so clinical suspicion should remain high even with normal values 3
• Check hemoglobin A1c and serum glucose to evaluate for vasculopathic etiologies 1
• Measure blood pressure, as hypertension can cause secondary headaches 1

Neuroimaging

• MRI with and without contrast is the preferred imaging modality for evaluating new-onset headache in elderly patients 1
• Up to 15% of patients over 65 with new-onset headaches have serious pathology including stroke, temporal arteritis, neoplasm, or subdural hematoma 3
• The yield of neuroimaging in elderly patients with new headache is substantially higher than in younger populations 3

Physical Examination Priorities

• Palpate temporal arteries for tenderness or decreased pulsation 1
• Assess for jaw claudication (pain with chewing), which is highly specific for GCA 1
• Perform complete neurological examination including mental status, cranial nerves, motor/sensory function, and fundoscopic examination for papilledema 1
• Check visual acuity and visual fields, as GCA can cause irreversible vision loss 3

Management Algorithm

If GCA is Suspected

• Initiate high-dose corticosteroids immediately without waiting for temporal artery biopsy if clinical suspicion is high 1
• Temporal artery biopsy can be false-negative in 5-44% of cases, so treatment should not be delayed 3
• Urgent ophthalmology referral is warranted given the risk of vision loss 1

If Imaging/Labs Reveal Other Secondary Causes

• Manage according to the specific etiology identified (tumor, subdural hematoma, stroke, etc.) 3
• Subdural hematomas can present with nonspecific headache patterns in elderly patients 3

If Workup is Negative for Secondary Causes

Only after excluding secondary etiologies should primary headache treatment be considered:

• NSAIDs (ibuprofen 400 mg or naproxen 500 mg) are first-line for acute treatment 1, 5
• Start with lower doses and titrate slowly in elderly patients 1
• Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache 5
• Consider preventive therapy with beta-blockers (metoprolol, propranolol) or topiramate if headaches occur more than 2 days per month 1, 5

Critical Pitfalls to Avoid

• Do not empirically treat as migraine or tension headache without workup—this presentation does not meet criteria for migraine (lacks pulsating quality, photophobia, phonophobia, nausea/vomiting) 4
• Do not rely solely on ESR to exclude GCA—it can be normal in up to 36% of cases 3
• Do not delay corticosteroids if GCA is suspected—vision loss can occur rapidly and is often irreversible 1, 3
• Monitor for cardiovascular and gastrointestinal risks with NSAIDs in elderly patients, as they account for 23.5% of adverse drug reaction hospitalizations in this population 5
• Avoid opioids and butalbital compounds, as they lead to dependency and rebound headaches 4, 5