From the Guidelines
A headache with eye flashing requires prompt medical evaluation as it may indicate a serious condition, and the workup should include a detailed medical history, physical examination with neurological assessment, and eye examination, with imaging studies such as CT or MRI of the brain considered to rule out structural abnormalities, as recommended by the most recent guidelines 1. The initial evaluation of a patient presenting with headache and photopsia (flashing lights) should prioritize identifying potential life-threatening conditions, such as aneurysmal subarachnoid hemorrhage, meningitis, or increased intracranial pressure.
- Key components of the workup include:
- A thorough medical history to identify red flags, such as sudden onset of severe headache, fever, stiff neck, or vision loss
- A physical examination with neurological assessment to evaluate for signs of increased intracranial pressure, meningismus, or focal neurological deficits
- An eye examination to assess for retinal detachment or other ocular abnormalities
- Imaging studies, such as CT or MRI of the brain, may be considered to rule out structural abnormalities, but should be guided by the presence of red flags or abnormal findings on physical examination, as recommended by recent guidelines 1.
- Additional tests, such as visual field testing, ophthalmoscopy, or lumbar puncture, may be necessary in certain cases to further evaluate the patient's condition.
- While waiting for medical attention, patients should rest in a quiet, dark room, avoid screens, and take over-the-counter pain relievers like acetaminophen (Tylenol) 650mg every 6 hours or ibuprofen (Advil) 400mg every 6 hours if not contraindicated by other medical conditions, as suggested by previous studies 1.
- However, the most recent and highest quality study 1 should be prioritized when making a definitive recommendation, and it emphasizes the importance of a thorough medical history and physical examination in guiding the workup and management of patients with headache and photopsia.
From the Research
Workup for Headache and Photopsia
The workup for a patient presenting with headache and photopsia (flashing lights) involves a focused history and physical examination to identify secondary headache and determine whether an immediate referral to the emergency department or a non-emergent referral to the neurologist is warranted 2.
- Key steps in the workup include:
- Proper categorization of the primary headache
- Attention to lifestyle and psychosocial factors
- Prescription of analgesics for acute pain relief
- Use of preventive medication when indicated
- Consideration of secondary headache and medication overuse headache
Differential Diagnosis of Photopsia
Photopsia is a relatively common symptom that can be associated with various etiologies, including:
- Posterior vitreous detachment
- Migraine with aura
- Migraine aura without headache
- Retinal break or detachment 3
- It is essential to perform specific procedures to differentially diagnose the responsible condition and deliver appropriate follow-up care.
Red Flags and Referral
Patients presenting with headache and photopsia should be evaluated for red flags, such as:
- Abrupt onset
- Neurologic signs
- Age 50 years and older
- Presence of cancer or immunosuppression
- Provocation by physical activities or postural changes 4, 5
- Referral to an ophthalmologist or neurologist may be necessary to rule out sight-threatening conditions or secondary headaches.
Treatment Options
Treatment options for headache and photopsia may include:
- Acetaminophen
- Nonsteroidal anti-inflammatory drugs
- Combination products that include caffeine
- Migraine-specific treatments, such as triptans, gepants, and lasmiditan 4
- Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, and calcitonin gene-related peptide monoclonal antibodies 4