What are the best first steps in assessing a 75‑year‑old female with a 4‑day history of migraine headache and no other symptoms?

Assessment of New-Onset Migraine in a 75-Year-Old Female

In a 75-year-old woman presenting with a 4-day headache labeled as "migraine," your first priority is to rule out secondary causes through careful history and examination for red flags, as new-onset headache at this age carries significant risk for dangerous pathology including temporal arteritis, stroke, subdural hematoma, and mass lesions. 1, 2, 3

Critical Red Flags to Assess Immediately

The following features mandate urgent investigation in this elderly patient:

• Temporal pattern: Sudden/thunderclap onset, progressive worsening over days, or "first or worst" headache suggests subarachnoid hemorrhage, stroke, or other acute pathology 2, 4, 5
• Temporal artery examination: Palpate for tenderness, nodularity, or reduced pulse; ask about jaw claudication and visual symptoms, as temporal arteritis affects 60-90% of patients over 50 with new headache 3
• Neurological deficits: Any focal signs, altered mental status, or visual deficits indicate structural lesion requiring immediate imaging 2, 4
• Systemic symptoms: Fever suggests infection (meningitis, encephalitis); weight loss or malignancy history raises concern for metastases 2, 4
• Valsalva or positional worsening: Suggests increased intracranial pressure from mass, hydrocephalus, or subdural hematoma 2, 5
• Recent trauma: Even minor head injury can cause subdural hematoma in elderly patients, particularly those on anticoagulation 3, 5

Specific History Elements to Elicit

Beyond red flags, obtain these details:

• Headache characteristics: True migraine is uncommon as new-onset at age 75; unilateral pulsating pain with nausea, photophobia, and phonophobia lasting 4-72 hours suggests primary migraine, but secondary causes must be excluded first 1
• Medication history: Anticoagulants increase risk of intracranial hemorrhage; recent medication changes may trigger headache 4, 5
• Comorbidities: Cancer, HIV, or immunosuppression dramatically increases likelihood of secondary headache 2
• Prior headache history: New headache pattern in someone with longstanding migraine still warrants investigation if character has changed 1, 6

Physical Examination Priorities

Perform focused examination targeting:

• Vital signs: Fever, hypertension (may indicate hypertensive emergency or posterior reversible encephalopathy syndrome) 4
• Temporal arteries: Bilateral palpation for tenderness, prominence, or absent pulse 3
• Complete neurological examination: Mental status, cranial nerves (especially visual fields and fundoscopy for papilledema), motor/sensory function, gait, and cerebellar signs 2, 4
• Neck examination: Meningismus suggests meningitis or subarachnoid hemorrhage 4, 5
• General examination: Signs of systemic illness, malignancy, or infection 2

Diagnostic Testing Algorithm

If any red flags are present, obtain urgent neuroimaging 2, 4:

• MRI brain with and without contrast is the preferred test for most secondary causes in non-emergent settings 2
• Non-contrast CT head if thunderclap onset, trauma, or concern for acute hemorrhage (95% sensitive on day 0 for subarachnoid hemorrhage, declining to 50% by 1 week) 3
• ESR and CRP if temporal arteritis suspected (though ESR can be normal in 10-36% of cases); temporal artery biopsy remains gold standard 3
• Lumbar puncture if CT negative but subarachnoid hemorrhage suspected (spectrophotometry detects xanthochromia in 100% at 12 hours through 2 weeks) 3

Critical Pitfall to Avoid

Do not assume this is primary migraine based on symptom description alone. Up to 15% of patients over 65 presenting with new-onset headache have serious pathology including stroke, temporal arteritis, neoplasm, or subdural hematoma 3. The yield of neuroimaging in elderly patients with new headache and normal examination still reveals significant pathology: brain tumors (0.8%), stroke (1.2%), subdural hematoma (0.2%), and other lesions 3. In patients over 50 with apparent late-onset migraine, suspect an underlying cause 1.

If Secondary Causes Are Excluded

Only after ruling out red flags and obtaining appropriate imaging (if indicated) should you consider this a primary headache disorder:

• Initiate headache diary to document frequency, duration, and associated symptoms, as patients often cannot accurately report headache patterns without prospective tracking 1
• Acute treatment: NSAIDs (ibuprofen 400-800 mg or naproxen 500-825 mg) remain first-line in elderly patients, though monitor carefully for gastrointestinal and cardiovascular risks 7, 8
• Avoid triptans in elderly patients due to cardiovascular disease risk, though evidence for increased events is limited 7
• Consider preventive therapy if acute treatment needed more than 2 days per month: beta-blockers (metoprolol 100-200 mg or propranolol 80-240 mg daily) are first-line, particularly with coexisting hypertension 7, 8