How should I evaluate and manage a 78-year-old woman with a new or worsening headache?

Evaluation and Management of Headache in a 78-Year-Old Woman

A 78-year-old woman presenting with new or worsening headache requires immediate evaluation to exclude life-threatening secondary causes, particularly subarachnoid hemorrhage (SAH), giant cell arteritis (GCA), and other serious intracranial pathology, before considering primary headache disorders like migraine.

Immediate Red Flag Assessment

The first priority is determining whether this represents a dangerous secondary headache requiring emergency intervention:

Critical Warning Signs to Assess Immediately

• Thunderclap headache (instantly peaking pain reaching maximum intensity within 1 hour) suggests SAH and requires immediate CT imaging 1
• Scalp tenderness, jaw claudication, or temporal pain suggests giant cell arteritis—check ESR and CRP immediately and perform temporal artery biopsy if elevated 1
• Neck pain or stiffness, witnessed loss of consciousness, or onset during exertion all meet Ottawa SAH Rule criteria requiring further investigation 1
• New focal neurological deficits, vision loss, diplopia, or altered consciousness suggest structural lesions, stroke, or increased intracranial pressure 1
• Fever with headache and stiff neck suggests meningitis requiring lumbar puncture after neuroimaging 1

Diagnostic Algorithm for Suspected SAH

If any Ottawa SAH Rule criteria are met (age ≥40 years alone qualifies this patient), proceed with immediate non-contrast CT scan 1:

• Within 6 hours of headache onset: High-quality CT read by neuroradiologist has 98.7% sensitivity; if negative, SAH is effectively ruled out 1
• After 6 hours or if CT non-diagnostic: Perform lumbar puncture with spectrophotometric analysis for xanthochromia (100% sensitivity, 95.2% specificity), ideally ≥12 hours after symptom onset 1
• If SAH confirmed: Immediate neurosurgical consultation, vascular imaging (CTA initially acceptable, though catheter angiography remains gold standard), and transfer to tertiary center 1

Evaluation for Giant Cell Arteritis

In any elderly patient with new headache plus scalp tenderness, jaw claudication, or pain, immediately check ESR and CRP 1:

• If elevated, perform temporal artery biopsy urgently and consider starting corticosteroids before biopsy results to prevent vision loss 1
• GCA is a medical emergency in the elderly and must not be missed 1

Neuroimaging Indications

Neuroimaging (MRI brain with and without contrast preferred) is indicated if 1:

• Any cranial neuropathies present (diplopia, facial weakness, vision changes)
• Elevated intraocular pressure or papilledema on fundoscopic examination
• Progressive or persistent neurological symptoms
• No clear vasculopathic risk factors to explain symptoms
• Lack of improvement within 4-6 weeks in patients with vasculopathic risk factors

If Secondary Causes Excluded: Primary Headache Evaluation

Only after ruling out dangerous secondary causes should primary headache disorders be considered:

Migraine in Older Adults: Special Considerations

Secondary headache, comorbidities, and adverse drug events are all substantially more likely in older patients, and the evidence base for all migraine drugs is poor in this age group 1:

• New-onset migraine after age 50 is uncommon; maintain high suspicion for secondary causes 1
• Medication adverse effects are more frequent and severe in elderly patients 1

Diagnostic Criteria for Migraine Without Aura

If migraine is suspected, confirm at least 5 attacks meeting these criteria 1:

• Headache lasting 4-72 hours untreated
• At least 2 of: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine activity
• At least 1 of: nausea/vomiting OR photophobia and phonophobia
• Not better explained by another diagnosis

Chronic Migraine Consideration

If headaches occur ≥15 days per month for >3 months with migraine features on ≥8 days per month, diagnose chronic migraine 2, 3:

• First rule out medication overuse headache (MOH): occurs when acute medications used ≥10 days per month 2, 3
• MOH mimics chronic migraine and prevents response to preventive therapy—requires medication withdrawal first 2, 3

Management Approach for Primary Headache

Acute Treatment (if migraine confirmed)

Limit acute medication to no more than twice weekly to prevent MOH 2, 3:

• First-line: NSAIDs (ibuprofen 400-800 mg, naproxen 275-550 mg) plus metoclopramide 10 mg if nausea present 3
• Avoid opioids, barbiturates, and ergot alkaloids due to dependency risk and MOH potential 3

Preventive Therapy Indications

Consider preventive therapy if headaches adversely affect patient ≥2 days per month or acute medications used more than twice weekly 3:

• First-line options in elderly: Propranolol 80-240 mg/day (avoid if cardiac contraindications), topiramate 100 mg/day (beneficial if obese due to weight loss effect), or amitriptyline 30-150 mg/day (especially if comorbid depression or insomnia) 3
• For chronic migraine specifically: Topiramate first-line; if failed, consider onabotulinumtoxinA 2, 3

Critical Comorbidity Management

Identify and treat depression, anxiety, sleep disorders, obesity, and chronic pain—their management directly improves headache outcomes 2, 3:

• Poor sleep quality and irregular sleep patterns increase attack susceptibility 3, 4
• Obesity is the most critical modifiable risk factor for chronic migraine transformation 3, 4

Common Pitfalls to Avoid

• Never assume new headache in elderly is benign migraine without excluding secondary causes first 1
• Never delay GCA workup in elderly with scalp tenderness or jaw claudication—vision loss is preventable 1
• Never initiate migraine preventive therapy without first ruling out and treating medication overuse headache 2
• Never allow unlimited acute medication use—strict twice-weekly limitation prevents MOH 2, 3