What is the next step in managing headaches in a 66-year-old male with a past medical history (PMH) of narcolepsy and spinal stenosis, currently on gabapentin and methylphenidate, presenting with constant bifrontal pressure-like headaches, 8/10 in severity, radiating to the back of both eyes, and unresponsive to Tylenol (acetaminophen)?

Urgent Neuroimaging Required Before Initiating Headache Treatment

This 66-year-old patient requires urgent neuroimaging (CT head without contrast, followed by MRI brain with venography if CT is negative) before any migraine-specific therapy is initiated, as the clinical presentation contains red flags for secondary headache disorders that demand immediate exclusion of life-threatening pathology. 1

Critical Red Flags Demanding Urgent Evaluation

• Positional worsening when lying down is fundamentally inconsistent with primary migraine and suggests increased intracranial pressure from venous sinus thrombosis, mass lesion, or other space-occupying pathology 1
• The bifrontal-to-retroorbital distribution with constant 8/10 severity unresponsive to acetaminophen indicates this is unlikely to be primary migraine, as acetaminophen should provide at least partial relief in true migraine 1
• Age 66 with new-onset headache pattern warrants neuroimaging, as the American Academy of Family Physicians recommends considering imaging in patients with newly onset headache in older persons 2
• The constant nature throughout the day without fluctuation is atypical for migraine, which typically has episodic patterns with pain-free intervals 2

Life-Threatening Diagnoses to Exclude Immediately

• Venous sinus thrombosis presents with positional headache worse when lying down, can mimic migraine, and requires urgent anticoagulation to prevent catastrophic outcomes 1
• Intracranial mass or tumor causes positional headache from increased intracranial pressure and can lead to herniation if untreated 1
• Idiopathic intracranial hypertension (IIH) should be considered given the age, bifrontal pressure-like quality, and retroorbital pain, though typically affects younger obese women 2

Immediate Diagnostic Algorithm

• Order CT head without contrast immediately as the initial screening test to rule out mass lesion, hemorrhage, or hydrocephalus 1
• If CT is negative but clinical suspicion remains high, proceed to MRI brain with MR venography to definitively exclude venous sinus thrombosis 1
• Perform careful fundoscopic examination to assess for papilledema, which would indicate elevated intracranial pressure and necessitate urgent ophthalmology consultation 2
• Check vital signs including blood pressure to exclude hypertensive emergency as a secondary cause 2

Symptomatic Management While Awaiting Imaging

• Provide IV ketorolac 30 mg (if no contraindications such as renal impairment or GI bleeding history) for immediate pain relief without masking neurological signs 3
• Add IV metoclopramide 10 mg for both nausea control and direct analgesic effects through central dopamine receptor antagonism 3
• Avoid opioids entirely, as they can mask neurological deterioration and lead to medication overuse headache 2, 3

Why Standard Migraine Treatment Must NOT Be Started First

• The positional component (worse lying down) is pathognomonic for increased intracranial pressure, not migraine, which typically improves with rest in a dark, quiet room 1
• Treating presumed migraine without imaging in the presence of red flags can delay diagnosis of life-threatening conditions such as venous sinus thrombosis or brain tumor, leading to catastrophic outcomes including death or permanent disability 1
• The failure of acetaminophen suggests the headache mechanism is not primarily driven by prostaglandin-mediated inflammation typical of migraine or tension-type headache 1
• Starting triptans or other migraine-specific therapy could provide false reassurance if partial response occurs, further delaying appropriate workup 1

Critical Medication Interaction Consideration

• Methylphenidate for narcolepsy can cause headaches as an adverse effect, but this would not explain the positional component or severity; however, document current dose and timing 4, 5
• Gabapentin for spinal stenosis is not associated with this headache pattern and may actually have mild preventive effects for migraine 2

If Imaging Is Completely Normal: Reassessment Strategy

• Only after negative CT and MRI/MRV should primary headache disorder be considered, at which point the differential includes new daily persistent headache, chronic tension-type headache, or atypical migraine 2
• Assess for medication overuse headache, though the patient denies current analgesic overuse beyond Tylenol 2
• Consider lumbar puncture with opening pressure measurement if imaging is negative but clinical suspicion for IIH remains, particularly if papilledema is present 2
• Initiate migraine preventive therapy immediately if diagnosed with chronic migraine (≥15 headache days per month), rather than relying on acute treatment alone 2

Common Pitfall to Avoid

Do not allow the patient's lack of "classic" migraine features (photophobia, phonophobia, nausea) to falsely reassure you that this is benign tension-type headache. The positional component and severity demand exclusion of secondary causes regardless of associated symptoms. 1