What is the best course of action for an elderly patient with a worsening headache over weeks, struggling to carry out daily activities?

Urgent Neuroimaging and Giant Cell Arteritis Evaluation Required

This elderly patient with a progressively worsening headache over weeks and functional impairment requires immediate neuroimaging (CT or MRI) and urgent evaluation for giant cell arteritis (GCA), as new-onset headache in patients over 50 years old is a critical red flag for life-threatening secondary causes. 1, 2

Immediate Diagnostic Workup

Neuroimaging is Mandatory First

• Obtain CT head or MRI brain immediately before any symptomatic treatment to exclude secondary causes including intracranial mass, subdural hematoma, cerebral venous thrombosis, or other life-threatening pathology 3, 1
• MRI brain is preferred for non-emergent evaluation in elderly patients with subacute worsening headache, as it has greater sensitivity for detecting clinically significant abnormalities 1, 2
• The combination of new-onset headache in a patient over 50 years old, progressive worsening over weeks, and functional impairment ("struggling to carry out activities") meets criteria for neuroimaging regardless of normal neurologic examination 1, 2

Giant Cell Arteritis Must Be Ruled Out Urgently

• Check ESR and CRP immediately in any patient over 50 with new or worsening headache, as GCA can cause irreversible vision loss if untreated 2, 4
• Specifically assess for jaw claudication, scalp tenderness, visual symptoms, and temporal artery abnormalities on examination 2, 4
• If GCA is suspected clinically, initiate high-dose corticosteroids (prednisone 40-60 mg daily) immediately before temporal artery biopsy, as treatment should not be delayed for diagnostic confirmation 2

Red Flag Assessment Using SNNOOP10 Framework

This patient exhibits multiple concerning features that mandate urgent evaluation 4:

• Age over 50 with new-onset headache (highest risk category for secondary causes) 1, 2
• Progressive worsening over weeks (suggests evolving pathology) 2, 4
• Functional impairment (indicates severity and potential for serious underlying cause) 4

Additional red flags to specifically assess 2, 4:

• Headache awakening patient from sleep
• Headache worsened by Valsalva maneuver or cough
• Any focal neurologic signs or symptoms
• Systemic symptoms (fever, weight loss, night sweats)
• History of cancer or immunosuppression

Management Algorithm After Imaging

If Neuroimaging Shows Secondary Cause

• Treat the underlying pathology according to specific diagnosis 3
• Subdural hematoma, mass lesions, or vascular abnormalities require neurosurgical consultation 1

If Neuroimaging is Normal

Acute Treatment Options (use cautiously in elderly):

• First-line: NSAIDs with gastroprotection - Ibuprofen 400 mg or naproxen 500 mg, but only after careful assessment of cardiovascular and renal function 5, 3
• The American Geriatrics Society warns that NSAIDs are implicated in 23.5% of adverse drug reaction hospitalizations in older adults 5
• Avoid NSAIDs if creatinine clearance <30 mL/min 5
• Limit acute medications to no more than 2 days per week to prevent medication-overuse headache 1, 5

Preventive Therapy Should Be Initiated:

• Given the duration (weeks) and functional impairment, this patient requires preventive therapy rather than just acute treatment 1, 5
• First-line preventive options for elderly patients: 1, 5
  • Beta-blockers (metoprolol or propranolol), though monitor for bradycardia and hypotension
  • Topiramate 50-100 mg daily (avoid if history of kidney stones or glaucoma)
  • Amitriptyline 10-25 mg at night (start low in elderly, monitor for anticholinergic effects)

Critical Pitfalls to Avoid

• Never dismiss new-onset headache in elderly patients as "just migraine" without neuroimaging - the prevalence of secondary causes is significantly higher in this age group 1, 2
• Do not prescribe opioids - they cause dependency, rebound headaches, cognitive impairment, and increased fall risk in elderly patients 5, 3
• Avoid triptans in elderly patients unless cardiovascular disease has been definitively excluded, as they have vasoconstrictive properties 6
• Do not use acetaminophen alone - it has not been shown to be effective for significant headache and may delay appropriate diagnosis 1, 3
• Monitor for medication-overuse headache - NSAIDs used ≥15 days per month or combination analgesics ≥10 days per month can perpetuate chronic daily headache 1, 5

When to Refer to Neurology

• If neuroimaging reveals any abnormality requiring specialist interpretation 1
• If headache persists despite appropriate preventive therapy after 2-3 months 1
• If diagnostic uncertainty remains after initial workup 4