What are the next steps for a 56-year-old male with a 1-month history of intermittent, throbbing headaches, exacerbated by head movement, with recent alcohol intake and attempted relief with aspirin and paracetamol (acetaminophen) without improvement, and a sensation of feeling cold, possibly developing an upper respiratory illness, with no known chronic medical conditions and taking berberine supplements?

Immediate Next Steps for This Patient

This patient requires urgent neuroimaging (CT or MRI brain) to rule out secondary causes of headache, particularly given the red flags of new-onset headache at age 56, occipital location, provocation by head movement, and failure to respond to standard analgesics. 1

Critical Red Flags Present

This presentation contains multiple concerning features that mandate exclusion of secondary headache disorders before considering primary headache diagnoses:

• Age of onset >50 years – New headache at 56 is a red flag requiring investigation for secondary causes including temporal arteritis, intracranial mass lesions, and cerebrovascular disease 1
• Occipital location with movement provocation – Headache worsened by head turning raises concern for cervicogenic pathology, posterior fossa lesions, or intracranial hypotension 1
• Failure of standard analgesics – Lack of response to aspirin and paracetamol is atypical for primary headache disorders 2, 3
• Progressive pattern over one month – Intermittent but persistent symptoms over weeks warrant structural evaluation 1

Immediate Diagnostic Workup

Neuroimaging is the priority:

• Brain MRI with and without contrast is preferred over CT for superior sensitivity in detecting structural lesions, intracranial hypotension (dural enhancement), subdural collections, and posterior fossa pathology 1
• CT head without contrast is acceptable if MRI unavailable or contraindicated, though less sensitive for subtle pathology 1
• MR or CT venography should be considered if imaging shows features suggestive of venous sinus thrombosis, particularly given recent alcohol use as a potential dehydration/hypercoagulable risk 1

Laboratory evaluation should include:

• ESR and CRP – Essential to screen for temporal arteritis given age >50 1
• Complete blood count – To assess for infection, anemia, or thrombocytosis 1
• Basic metabolic panel – Dehydration from alcohol use may contribute 1

Differential Diagnosis Considerations

While awaiting imaging, the differential includes:

Secondary headache disorders (must exclude first):

• Intracranial hypotension – Occipital headache, though typically positional (worse upright, better supine), can present with movement provocation; dural enhancement on MRI is diagnostic 1
• Cervicogenic headache – Occipital pain provoked by neck movement, though typically unilateral 1
• Posterior fossa mass or Chiari malformation – Can cause occipital headache worsened by Valsalva or movement 1
• Temporal arteritis – Age >50 with new headache mandates consideration; may present with occipital involvement 1
• Subdural hematoma – Recent heavy alcohol use increases fall risk; can present with subacute headache 1

Primary headache disorders (only after secondary causes excluded):

• Tension-type headache – Possible given bilateral, non-throbbing quality and lack of migraine features, though occipital location and movement provocation are atypical 4
• Migraine without aura – Less likely given lack of nausea, photophobia, phonophobia, and throbbing quality described as "tolerable" 1

Management Pending Workup

While awaiting imaging:

• Avoid further analgesic use until diagnosis established, as medication overuse headache can develop with frequent use (≥15 days/month for NSAIDs, ≥10 days/month for combination analgesics) 5
• Maintain hydration given recent alcohol use and possible URI symptoms 5
• Document headache characteristics including frequency, duration, severity, and triggers in a headache diary 1
• Avoid alcohol until diagnosis established 5

Urgent evaluation is needed if:

• Sudden severe worsening of headache intensity (thunderclap pattern) 1
• Development of focal neurological deficits, altered consciousness, or seizure 1
• Fever with neck stiffness 1
• New visual changes or diplopia 1

Common Pitfalls to Avoid

• Do not treat empirically as primary headache disorder without first excluding secondary causes in a patient >50 with new-onset headache 1
• Do not attribute symptoms solely to alcohol hangover when the patient himself reports this feels different from prior hangovers 1
• Do not delay imaging based on low pain severity (2-3/10); secondary headaches can present with mild-moderate pain 1
• Do not overlook temporal arteritis – ESR/CRP must be checked in all patients >50 with new headache, even without classic jaw claudication or visual symptoms 1

After Secondary Causes Excluded

Only if neuroimaging and laboratory workup are normal, consider trial of:

• NSAIDs at adequate doses (ibuprofen 400-600 mg or naproxen 500-550 mg) rather than aspirin alone, as these have superior evidence for tension-type headache 4
• Combination therapy with acetaminophen 1000 mg + aspirin 500 mg + caffeine 65 mg has strong evidence for headache relief if migraine features emerge 6
• Preventive therapy consideration if headaches persist on ≥2 days per month despite optimized acute treatment 1, 5

The priority remains excluding life-threatening secondary causes before any therapeutic trial, given this patient's age and red flag features.