New Onset Headaches After Age 50: Critical Conditions to Rule Out

Introduction to New Onset Headaches

The American Academy of Neurology recommends aggressively investigating secondary causes of new onset headaches in patients over 50, as the incidence of life-threatening secondary headaches increases substantially with age 1
Migraine typically remits with older age, making new apparent "migraine" after 50 inherently suspicious for an underlying secondary cause 1

The American Heart Association recommends obtaining non-contrast head CT within 6 hours of symptom onset for suspected subarachnoid hemorrhage, with 98.7% sensitivity when interpreted by fellowship-trained neuroradiologists 3, 4
If CT is negative but clinical suspicion remains high for subarachnoid hemorrhage, the American Heart Association recommends performing lumbar puncture >6 hours after symptom onset with spectrophotometric analysis for xanthochromia, which has 100% sensitivity 3, 4

The American College of Emergency Physicians recommends obtaining neuroimaging if systemic signs or symptoms such as fever, weight loss, or malaise are present 1

The American Academy of Neurology recommends checking vital signs, including blood pressure, as part of the immediate assessment of new onset headaches in patients over 50 2
The American College of Rheumatology recommends checking ESR and C-reactive protein in all patients over 50 with new headache to screen for temporal arteritis, although ESR can be normal in 10-36% of biopsy-proven cases 2

The American Headache Society recommends not assuming migraine without thorough investigation in patients over 50, as late-onset migraine requires exclusion of secondary causes 1, 2
The American Heart Association recommends not delaying CT beyond 6 hours if subarachnoid hemorrhage is suspected, as sensitivity drops from 95% on day 0 to 74% by day 3 3, 4