Urgent Neuroimaging Required for This Elderly Patient
This elderly man with new-onset, severe, constant headache unresponsive to acetaminophen requires immediate neuroimaging and urgent evaluation to rule out life-threatening secondary causes, particularly temporal arteritis, intracranial hemorrhage, or mass lesion. 1
Critical Red Flags Present
This presentation contains multiple concerning features that mandate urgent workup:
- New-onset headache in elderly patient (>50 years): This is a major red flag requiring neuroimaging, as up to 15% of elderly patients with new-onset headaches have serious pathology including stroke, temporal arteritis, neoplasm, or subdural hematoma 2
- Constant severe pain (8/10) for one week: Progressive or persistent severe headache in an older person warrants conservative approach with neuroimaging 1
- Failure to respond to standard analgesics: Acetaminophen-refractory headache raises concern for secondary causes 1
- Pressure-like pain behind eyes with bilateral radiation: While this could suggest primary headache, the age and severity make secondary causes more likely 3, 4
Immediate Diagnostic Workup Required
Neuroimaging
- MRI brain is the diagnostic test of choice for this patient to evaluate for mass lesion, stroke, subdural hematoma, or other structural pathology 4
- CT brain is acceptable if MRI unavailable, though less sensitive for certain pathologies 4
Laboratory Testing
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are essential to evaluate for temporal arteritis, which presents with new-onset headache in patients over 50 and can cause permanent vision loss if untreated 2
- Note that ESR can be normal in 10-36% of temporal arteritis cases, so clinical suspicion should guide temporal artery biopsy even with normal labs 2
Physical Examination Priorities
- Palpate temporal arteries for tenderness, nodularity, or decreased pulsation 2
- Complete neurologic examination to identify any focal deficits 1
- Fundoscopic examination to assess for papilledema or other signs of increased intracranial pressure 4
- Check blood pressure to rule out hypertensive emergency 4
Acute Pain Management While Awaiting Workup
First-Line Treatment Options
- Ibuprofen 400-800 mg or naproxen sodium 500-825 mg are preferred first-line alternatives to acetaminophen for headache in elderly patients 5
- Aspirin 500-1000 mg is another effective option 5
- Start with lower doses and monitor closely for gastrointestinal and cardiovascular risks, as NSAIDs are implicated in 23.5% of adverse drug reaction hospitalizations in older adults 5
Critical Safety Monitoring
- Avoid NSAIDs if creatinine clearance <30 mL/min due to renal impairment risk 5
- Monitor blood pressure regularly when using NSAIDs in elderly patients due to higher cardiovascular disease prevalence 5
- Limit NSAID use to no more than twice weekly to prevent medication-overuse headache 5
Alternative Options if NSAIDs Contraindicated
- Metoclopramide 10 mg provides both antiemetic effects and synergistic analgesia 5
- Prochlorperazine 10 mg is an effective alternative for headache relief 5
- Avoid opioids as routine therapy due to risks of dependency, rebound headaches, cognitive impairment, and falls in elderly patients 5
Common Pitfalls to Avoid
- Do not assume this is a primary headache disorder based on symptom description alone—age and severity demand exclusion of secondary causes first 3, 2
- Do not delay neuroimaging while attempting empiric treatment, as this could miss time-sensitive diagnoses like temporal arteritis or subdural hematoma 2
- Do not rely solely on ESR to rule out temporal arteritis, as it can be falsely normal in up to 36% of cases 2
- Avoid prescribing triptans until secondary causes are excluded, as they are contraindicated in certain vascular conditions 6
When to Consider Emergency Department Referral
Immediate ED referral is warranted if any of the following develop: