What is the recommended evaluation and management for an 82‑year‑old woman presenting one month after a fall with new‑onset headache, otalgia, and photophobia?

Urgent Evaluation for Chronic Subdural Hematoma

This 82-year-old woman presenting one month after a fall with new headaches, ear pain, and photophobia requires immediate neuroimaging with CT or MRI brain to rule out chronic subdural hematoma—a life-threatening condition that commonly presents with delayed symptoms in elderly patients after seemingly minor head trauma. 1

Immediate Diagnostic Workup

Neuroimaging (First Priority)

• Obtain non-contrast CT head immediately to evaluate for chronic subdural hematoma, which can present weeks after trauma with progressive headache and neurological symptoms 1
• MRI brain with and without contrast is preferred if CT is non-diagnostic, as it provides superior soft tissue detail for intracranial complications 2, 3
• The one-month delay between fall and symptom onset is classic for chronic subdural hematoma in elderly patients, who often have brain atrophy allowing slow blood accumulation 1

Critical History Elements to Document

• Exact circumstances of the original fall, including any loss of consciousness or immediate symptoms 1
• Progressive nature of headache (worsening over time suggests mass effect) 3
• Associated neurological symptoms: confusion, weakness, gait changes, or visual disturbances 1
• Medication review, particularly anticoagulants or antiplatelet agents that increase bleeding risk 1

Physical Examination Priorities

• Complete neurological examination with emphasis on mental status changes, focal motor deficits, cranial nerve abnormalities, and gait assessment 1, 3
• Fundoscopic examination for papilledema indicating increased intracranial pressure 3
• Orthostatic blood pressure measurement 1
• "Get Up and Go Test" to assess mobility and fall risk 1

Differential Diagnosis Considerations

High-Risk Conditions to Rule Out

• Chronic subdural hematoma (most likely given timeline and age) 1
• Giant cell arteritis if scalp tenderness or jaw claudication present—check ESR and CRP urgently 3
• Intracranial infection (subdural empyema, meningitis) if fever or meningismus present 2
• Delayed subarachnoid hemorrhage from sentinel bleed 2

Secondary Headache Red Flags Present

• New headache after age 50 is a red flag requiring urgent evaluation 3
• Progressive worsening headache suggests structural lesion 3
• Photophobia in elderly patient with trauma history warrants imaging 3

Additional Diagnostic Testing

• Blood pressure measurement to rule out hypertensive emergency 3
• If giant cell arteritis suspected: ESR, CRP, and temporal artery examination 3
• Consider lumbar puncture only after neuroimaging excludes mass lesion if infection suspected 2

Management Algorithm

If Chronic Subdural Hematoma Confirmed

• Immediate neurosurgical consultation for potential surgical evacuation 1
• Hospital admission for monitoring and intervention 1
• Hold anticoagulants/antiplatelets pending neurosurgical evaluation 1

If Imaging Negative but Symptoms Persist

• Consider giant cell arteritis: start high-dose corticosteroids immediately if clinical suspicion high while awaiting temporal artery biopsy 3
• Evaluate for post-traumatic headache syndrome 3
• Screen for medication overuse if patient taking frequent analgesics 3

If Migraine Diagnosed (Only After Excluding Secondary Causes)

• First-line acute treatment: NSAIDs (ibuprofen 400 mg or naproxen 500-825 mg) 3
• Avoid triptans in elderly due to cardiovascular risk 3
• Consider preventive therapy with beta-blockers (particularly if comorbid cardiovascular disease) or topiramate starting at 25 mg 3

Critical Pitfalls to Avoid

• Never dismiss delayed post-traumatic symptoms in elderly patients—chronic subdural hematoma can be fatal if missed 1
• Do not attribute photophobia solely to migraine without neuroimaging in this context 3
• Elderly patients may have "occult" traumatic injuries not apparent on initial presentation 1
• The ear pain may represent referred pain from intracranial pathology rather than primary otologic disease 2
• Do not perform lumbar puncture before imaging, as this can cause herniation if mass lesion present 2

Disposition and Follow-Up

• If neuroimaging shows acute pathology: immediate hospital admission 1
• If discharged: arrange expedited outpatient neurology follow-up within 48-72 hours 1
• Home safety assessment and fall prevention strategies essential given history 1
• Consider physical therapy referral for gait training and balance assessment 1