What is the initial approach for a patient presenting to the ER with lightheadedness, blurred vision, and headache (HA)?

From the Guidelines

The initial approach for a patient presenting to the ER with lightheadedness, blurred vision, and headache should focus on rapid assessment of vital signs and neurological status to rule out life-threatening conditions, as recommended by the most recent guidelines 1. The patient's symptoms could be indicative of various conditions, ranging from benign to life-threatening, such as stroke, subarachnoid hemorrhage, or hypertensive emergency.

• Begin with an ABC assessment (airway, breathing, circulation) and obtain vital signs including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.
• Perform a focused neurological examination including mental status, cranial nerves, motor strength, sensation, coordination, and check for signs of meningeal irritation.
• Order immediate laboratory tests including complete blood count, basic metabolic panel, glucose level, and consider toxicology screening if indicated.
• Imaging studies should include a non-contrast head CT to rule out intracranial hemorrhage, mass, or other structural abnormalities, as suggested by the guidelines for patients with symptoms of possible ischemic origin 1.
• If the patient has severely elevated blood pressure, consider administering antihypertensives such as IV labetalol (10-20 mg) or hydralazine (5-10 mg) to reduce the risk of end-organ damage.
• For severe headache, provide analgesia with acetaminophen 1000 mg or ketorolac 30 mg IV if not contraindicated. It is essential to note that the initial task in managing a patient who presents with headache is to take a thorough history and perform a physical examination, as stated in the management of acute migraine headache study 1. However, given the potential for life-threatening conditions, the approach should prioritize rapid assessment and stabilization over detailed history-taking in the initial stages.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Approach to Patient Presenting with Lightheadedness, Blurred Vision, and Headache

The initial approach to a patient presenting with lightheadedness, blurred vision, and headache (HA) in the ER involves a careful history and physical examination to rule out life-threatening secondary causes of headache 2, 3, 4, 5.

• Key considerations in the history include:
  • Onset and duration of symptoms
  • Characteristics of the headache (e.g., location, severity, triggers)
  • Presence of aura or other neurological symptoms
  • Medical history and medications
• Physical examination should include:
  • Complete neurological examination
  • Vital signs (e.g., blood pressure, temperature)
  • Ophthalmological examination (e.g., visual acuity, intraocular pressure) if blurred vision is present 6
• The differential diagnosis for headache is broad and includes primary causes (e.g., migraine, tension headache) and secondary causes (e.g., subarachnoid hemorrhage, meningitis, glaucoma) 3, 4, 5

Diagnostic Workup

The diagnostic workup for a patient presenting with lightheadedness, blurred vision, and headache may include:

• Neuroimaging (e.g., CT or MRI) if secondary causes are suspected 3, 4
• Serum or spinal fluid analysis if indicated (e.g., lumbar puncture) 3, 4
• Ophthalmological testing (e.g., slit lamp examination) if blurred vision is present 6

Management

Management of the patient will depend on the underlying cause of the symptoms. If a secondary cause is identified, treatment will be targeted at that condition. If a primary headache disorder is diagnosed, treatment may include pharmacological therapy (e.g., NSAIDs, triptans) and referral to a headache specialist 4.