What is the initial workup for a patient presenting with headache and blurry vision?

Initial Workup for Headache with Blurry Vision

The initial workup for a patient presenting with headache and blurry vision should include a thorough neuro-ophthalmologic examination and targeted neuroimaging, with MRI being the preferred modality for non-emergent situations and CT for acute presentations. 1

Initial Clinical Evaluation

History Taking - Key Elements

• Headache characteristics:
  • Onset (sudden vs. gradual)
  • Duration and frequency
  • Quality (pulsating, throbbing, pressure)
  • Severity (mild, moderate, severe)
  • Location (unilateral, bilateral, focal)
  • Aggravating/alleviating factors
  • Associated symptoms (nausea, vomiting)
• Visual symptoms:
  • Onset of blurry vision (sudden vs. gradual)
  • Unilateral vs. bilateral
  • Constant vs. intermittent
  • Associated visual phenomena (flashing lights, visual field defects)
• Red flags requiring urgent neuroimaging:
  • "Worst headache of life"
  • New headache pattern after age 50
  • Headache worsened by Valsalva maneuver
  • Headache that awakens patient from sleep
  • Progressively worsening headache pattern 1

Physical Examination

• Complete neuro-ophthalmologic examination:
  • Visual acuity testing
  • Visual field assessment
  • Color vision testing
  • Pupillary examination (size, shape, reactivity, relative afferent pupillary defect)
  • Slit-lamp biomicroscopy (if available)
  • Fundoscopy (crucial to evaluate for papilledema) 2, 3
• Neurological examination:
  • Cranial nerve assessment
  • Motor and sensory examination
  • Coordination testing
  • Reflex testing

Diagnostic Workup Algorithm

Step 1: Identify Red Flags Requiring Immediate Neuroimaging

• Abnormal neurologic examination findings
• Sudden onset severe headache ("worst headache of life")
• Headache with focal neurological deficits
• Papilledema on fundoscopic examination
• Headache worsened by Valsalva maneuver
• New headache pattern after age 50
• Headache that awakens patient from sleep 1

Step 2: Choose Appropriate Neuroimaging Based on Presentation

For Emergent Situations:

• CT brain without contrast as initial imaging
• Consider CT venography if cerebral venous thrombosis is suspected 2

For Non-Emergent Situations:

• MRI brain with contrast is preferred over CT for most non-emergent situations 1
• Consider specific protocols based on suspected etiology:
  • For suspected optic neuritis: MRI of orbits and brain without and with contrast 2
  • For suspected angle-closure glaucoma: Ophthalmologic evaluation takes precedence over neuroimaging 2

Step 3: Consider Specific Etiologies Based on Clinical Presentation

Primary Angle-Closure Disease

• Consider in patients with:
  • Hyperopia
  • Shallow anterior chamber
  • Family history of angle closure
  • Use of medications that can cause angle narrowing (sulfonamides, topiramate, anticholinergics) 2

Optic Neuritis

• Consider in patients with:
  • Painful visual loss (can be unilateral or bilateral)
  • Relative afferent pupillary defect
  • Central visual field defect
  • Normal or swollen optic disc 2

Cerebral Venous Thrombosis

• Consider in patients with:
  • Headache with increasing severity
  • Papilledema
  • Focal neurological deficits
  • Risk factors (hypercoagulable states, polycythemia) 2, 4

Primary Headache Disorders with Visual Symptoms

• Consider in patients with:
  • Recurrent headaches
  • Visual aura
  • Photophobia
  • Normal neurological examination
  • No concerning findings on fundoscopy 1, 5

Common Pitfalls and Caveats

1. Missing Angle-Closure Glaucoma: Acute angle-closure glaucoma can present with headache and blurry vision and requires immediate ophthalmologic intervention. Look for mid-dilated pupil, corneal edema, and very high intraocular pressure. 2

2. Overlooking Papilledema: Careful fundoscopic examination is essential as papilledema may indicate increased intracranial pressure requiring urgent neuroimaging and further workup. 1, 4

3. Unnecessary Neuroimaging: Avoid neuroimaging if it will not lead to a change in management, particularly in patients with clear features of primary headache disorders and normal neurological examination. 2, 1

4. Misdiagnosing "Sinus Headache": Many patients with migraine are misdiagnosed with sinus headache. Cranial autonomic symptoms like rhinorrhea can occur in migraine. 2

5. Inadequate Medication History: Certain medications can cause visual disturbances and headache, including sulfonamides, topiramate, and drugs with anticholinergic effects. 2

By following this systematic approach, clinicians can effectively evaluate patients presenting with headache and blurry vision, ensuring appropriate diagnosis and management while avoiding unnecessary testing.