What is the appropriate workup and treatment for a 67-year-old patient presenting with headaches, considering potential underlying conditions such as brain tumor, stroke, or giant cell arteritis?

Headache Workup in a 67-Year-Old Patient

Obtain immediate neuroimaging with MRI brain with and without contrast before any symptomatic treatment, as new-onset headache after age 50 is the highest-risk red flag for life-threatening secondary causes including intracranial mass, subdural hematoma, stroke, and cerebral venous thrombosis. 1, 2

Critical Red Flags Requiring Urgent Evaluation

Your 67-year-old patient meets the single most important red flag criterion—new headache after age 50—which mandates immediate imaging regardless of normal neurologic examination. 1, 2, 3 Additional red flags to assess include:

• Thunderclap onset (sudden, severe headache reaching maximum intensity within seconds to minutes) 1, 3
• Progressive worsening pattern over days to weeks 2, 3
• Headache awakening patient from sleep 1, 3
• Worsening with Valsalva maneuver (coughing, straining, bending) 1, 3
• Scalp tenderness or jaw claudication (suspect giant cell arteritis) 1, 3
• Focal neurologic deficits (weakness, numbness, visual changes, aphasia) 3, 4
• Systemic symptoms (fever, weight loss, night sweats) 2

Essential Physical Examination Components

Perform a complete neurologic examination focusing on: 1

• Mental status assessment (orientation, memory, attention) 1
• Cranial nerve function (visual fields, pupillary response, extraocular movements, facial sensation and strength) 1
• Motor and sensory examination (strength, reflexes, coordination, gait) 1
• Fundoscopic examination for papilledema (suggests elevated intracranial pressure) 1
• Blood pressure measurement (hypertensive emergency can present as headache) 1
• Temporal artery palpation (tenderness, decreased pulse, or nodularity suggests giant cell arteritis) 1

Immediate Laboratory Testing

Order the following blood tests concurrently with neuroimaging: 1

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to rule out giant cell arteritis, which is a medical emergency requiring immediate high-dose corticosteroids to prevent permanent vision loss 1
• Complete blood count (infection, anemia) 5
• Comprehensive metabolic panel (electrolyte abnormalities, renal function, hepatic function) 5
• Hemoglobin A1c and serum glucose if vasculopathic etiology suspected 1

Neuroimaging Protocol

MRI brain with and without contrast is the preferred imaging modality for evaluating new-onset headache in elderly patients, as it provides superior detection of ischemic stroke, venous thrombosis, leptomeningeal disease, and small masses compared to CT. 1, 2, 3 However, if MRI is contraindicated or unavailable, obtain CT head immediately. 2

The combination of age over 50, new-onset headache, and any progressive pattern or functional impairment meets absolute criteria for neuroimaging regardless of normal examination findings. 2 Never dismiss new-onset headache in elderly patients as "just migraine" without imaging, as the prevalence of dangerous secondary causes is significantly higher in this age group. 2

Differential Diagnosis Priority

Life-Threatening Secondary Causes (Rule Out First):

• Intracranial mass or metastasis 2
• Subdural hematoma (especially with anticoagulation or fall history) 2
• Ischemic or hemorrhagic stroke 2
• Cerebral venous thrombosis (can present with isolated headache) 6, 2
• Giant cell arteritis (medical emergency in patients over 50) 1, 3
• Meningitis or encephalitis (if fever, altered mental status, or meningismus present) 6, 4
• Intracranial hemorrhage (subarachnoid, intracerebral) 2

Primary Headache Disorders (Diagnose Only After Excluding Secondary Causes):

• Migraine (can present de novo in elderly, but uncommon) 1, 7
• Tension-type headache 5, 7
• Cluster headache 7
• Hypnic headache (rare, specific to elderly patients, awakens from sleep at consistent time) 7

Management Algorithm After Imaging

If Imaging Reveals Secondary Cause:

Treat the underlying pathology immediately—this takes absolute priority over symptomatic headache management. 2 For example:

• Giant cell arteritis: Start prednisone 40-60 mg daily immediately, even before temporal artery biopsy 1
• Intracranial mass: Urgent neurosurgery consultation 2
• Stroke: Activate stroke protocol per institutional guidelines 2

If Imaging is Normal and Secondary Causes Excluded:

Acute symptomatic treatment (use sparingly, maximum 2 days per week to prevent medication-overuse headache): 2, 3

• First-line: NSAIDs with gastroprotection (ibuprofen 400 mg or naproxen 500 mg), but only after assessing cardiovascular and renal function 2, 3
• Avoid NSAIDs if creatinine clearance <30 mL/min 2
• Antiemetics if nausea present (metoclopramide 10 mg or prochlorperazine 10 mg) 3
• Never prescribe opioids for routine headache management due to dependency risk, rebound headaches, cognitive impairment, and increased fall risk in elderly patients 2, 3

Preventive therapy (initiate if headaches persist with duration of weeks and functional impairment): 2

• First-line options: Beta-blockers (metoprolol or propranolol), topiramate 25-100 mg daily (start low, titrate slowly), or amitriptyline 10-25 mg at bedtime 1, 2, 3
• Beta-blockers may be particularly beneficial if comorbid cardiovascular conditions exist 1
• Start all preventive medications at low doses and titrate slowly over 2-3 months to assess efficacy and minimize side effects in elderly patients 1, 3

Critical Pitfalls to Avoid

• Never treat symptomatically before obtaining neuroimaging in a patient over 50 with new-onset headache 2
• Do not assume primary headache disorder without imaging, as secondary causes are far more common in this age group than new-onset primary headaches 2, 7
• Avoid triptans in elderly patients due to high prevalence of cardiovascular disease, though evidence for increased cardiovascular events is limited 1
• Monitor for medication-overuse headache: NSAIDs used ≥15 days per month or combination analgesics ≥10 days per month perpetuate chronic daily headache 2, 5
• Do not delay giant cell arteritis workup: If ESR/CRP elevated with compatible symptoms, start corticosteroids immediately before temporal artery biopsy to prevent irreversible vision loss 1

Follow-Up Strategy

• Encourage headache diary to track frequency, severity, triggers, and medication use 1, 3
• Evaluate treatment response within 2-3 months after initiating preventive therapy, then every 6-12 months 1, 3
• Consider neurology referral if uncertain diagnosis, poor response to preventive strategies, or headache with motor weakness 3