How would you work up a 22-year-old complaining of attention-type headache, tremor, exophthalmos (bulging of the eyes), and dizziness for 4 days?

Diagnostic Workup for a 22-Year-Old with Headache, Tremor, Exophthalmos, and Dizziness

The most appropriate initial workup for a 22-year-old with attention-type headache, tremor, exophthalmos, and dizziness for 4 days should include brain MRI with contrast, thyroid function tests, and neurological consultation due to the high suspicion for hyperthyroidism with possible central nervous system involvement.

Initial Assessment and Differential Diagnosis

The constellation of symptoms suggests several possible diagnoses that require systematic evaluation:

• Hyperthyroidism/Graves' disease: The combination of exophthalmos (bulging eyes) and tremor strongly suggests thyroid dysfunction, particularly Graves' disease 1
• Vestibular migraine: The headache and dizziness could represent vestibular migraine, which can mimic other causes of vertigo 1
• Central nervous system pathology: The combination of headache, dizziness, and neurological symptoms (tremor) warrants evaluation for intracranial pathology 1
• Ménière's disease: Though less likely given the exophthalmos, this could explain the dizziness component 1

Recommended Diagnostic Workup

1. Laboratory Testing

• Complete thyroid function panel:

  • TSH, free T4, free T3, and thyroid antibodies (particularly TSI - thyroid stimulating immunoglobulin) 1
  • These tests are essential given the exophthalmos and tremor, which are classic signs of hyperthyroidism

• Complete blood count and basic metabolic panel:

  • To assess for systemic illness, infection, or electrolyte abnormalities that could contribute to symptoms 1

2. Neuroimaging

• Brain MRI with contrast:

  • Preferred over CT due to superior soft tissue contrast and ability to detect subtle abnormalities 1
  • Should include dedicated orbital views to evaluate exophthalmos and orbital structures 1
  • Important to rule out central causes of vertigo, which can mimic peripheral vestibular disorders 1

• Consider MRA head and neck:

  • If there is concern for vascular pathology based on initial MRI findings 1

3. Specialty Evaluations

• Neurological consultation:

  • For comprehensive assessment of headache, tremor, and dizziness 1
  • Detailed neurological examination to assess for focal deficits 1

• Ophthalmology evaluation:

  • To assess exophthalmos and rule out other ocular pathology 1
  • Should include funduscopic examination to check for papilledema or optic atrophy 1

• Otolaryngology consultation:

  • If vestibular symptoms are prominent 1
  • May perform vestibular testing to characterize dizziness 1

4. Specific Tests for Dizziness/Vertigo

• Dix-Hallpike maneuver:

  • To assess for benign paroxysmal positional vertigo (BPPV) 1
  • Important to distinguish between peripheral and central causes of vertigo 1

• Vestibular function tests:

  • If initial evaluation suggests peripheral vestibular dysfunction 1

Clinical Reasoning and Approach

1. First priority: Rule out serious neurological conditions

   • The combination of headache, neurological symptoms (tremor), and dizziness warrants urgent neuroimaging 1
   • Central causes of vertigo can mimic peripheral vestibular disorders but require different management 1

2. Second priority: Evaluate for hyperthyroidism

   • Exophthalmos with tremor strongly suggests Graves' disease or other thyroid disorders 1
   • Thyroid dysfunction can exacerbate or contribute to headaches and dizziness 1

3. Third priority: Characterize headache pattern

   • Determine if headache fits criteria for migraine, tension-type headache, or other primary headache disorder 1
   • Vestibular migraine can present with dizziness and headache 1

Common Pitfalls to Avoid

• Focusing only on one symptom: The constellation of symptoms suggests a systemic process or multiple conditions rather than isolated problems 1
• Attributing symptoms solely to migraine: While vestibular migraine is common, the presence of exophthalmos suggests additional pathology 1
• Delaying neuroimaging: Given the multiple neurological symptoms, prompt imaging is essential 1
• Missing thyroid disease: Exophthalmos with tremor is highly suggestive of thyroid dysfunction and should not be overlooked 1
• Inadequate vestibular assessment: Proper characterization of dizziness is essential for diagnosis 1

Follow-up Recommendations

• Close follow-up within 1-2 weeks after initial evaluation 1
• Adjustment of diagnostic and treatment plan based on initial test results 1
• Consider referral to an endocrinologist if thyroid dysfunction is confirmed 1

This comprehensive approach ensures that potentially serious conditions are not missed while providing appropriate management for this complex presentation of symptoms.