Figure 15.1

Approach to new headaches or a change in existing headache in the elderly.

Neurological examination of the elderly patient with complaints of headache assesses for neurological deficits while examining cranial nerves, motor and sensory function. Mental status and altered level of consciousness are generally associated with more systemic or intracranial processes. Abnormalities of balance, coordination, and reflexes may be seen in intracranial or spinal pathology. General physical examination should include assessments of vital signs and searching for any ocular and cardiopulmonary abnormalities suggesting of headaches from ophthalmologic and cardiogenic causes. If there is a history concerning for trauma or falls, examination of the head and scalp along with the skin and musculoskeletal system to assess for injuries is necessary.

Additional laboratory workup is guided by the history and exam to identify secondary causes. Laboratory studies may include checking for infectious etiologies, hormone distortions, toxicology studies, and comprehensive metabolic panels may be indicated depending on the history. Neuroimaging is indicated when there are red flag symptoms reported. Although there is yet to be consensus guidelines on imaging with CT or MRI of the brain, imaging should also be considered with new onset headache in the elderly. CT/MRI should also be done if mental status changes, focal neurologic deficits, seizures, post-trauma headaches, or papilledema are present, with the goal of evaluating for any intracranial lesion .

Conclusion

Neurological problems are common in elderly patients. Weakness, sensory complaints and headaches are very common complaints in any medical setting and seizures are becoming increasingly prevalent with advancing age. Significant disability can occur if neurological issues are not addressed in the elderly patient. It is important for the primary care clinician to become familiar with these disorders in order to promptly recognize and manage the underlying cause to help alleviate unnecessary decreases in the quality of life of older patients.

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