What are the possible causes and treatments for forehead pressure and eye discomfort?

Forehead Pressure and Eye Discomfort: Differential Diagnosis and Management

The most critical immediate concern is to rule out acute angle-closure glaucoma, which presents with forehead/eye pain and can cause rapid, irreversible vision loss within hours if untreated. 1

Immediate Assessment Required

Red Flag Features Requiring Urgent Evaluation

• Acute angle-closure crisis presents with severe eye pain, forehead pressure, blurred vision with halos around lights, mid-dilated unreactive pupil, corneal edema, conjunctival injection, nausea/vomiting, and markedly elevated intraocular pressure 1
• Intermittent angle closure causes transient episodes of bilateral forehead pressure, eye discomfort, blurred vision, and halos around lights that resolve spontaneously—this is pathognomonic and represents warning episodes before potentially blinding acute attacks 2
• The combination of bilateral presentation, transient nature, opaque vision, and halos is specifically diagnostic for intermittent angle closure 2

Critical Examination Components

• Measure intraocular pressure immediately in any patient with forehead pressure and eye discomfort to detect elevated IOP 1
• Perform gonioscopy to assess the iridocorneal angle and detect angle closure—this cannot be deferred if angle closure is suspected 1, 2
• Pupil examination for mid-dilation, asymmetry, or poor reactivity suggesting acute attack 1
• Slit-lamp examination for corneal edema, shallow anterior chamber, conjunctival hyperemia, and anterior chamber inflammation 1
• Visual acuity testing and confrontational visual fields 1

Differential Diagnosis by Clinical Pattern

Sinus-Related Causes

• Airplane headache (AHA) occurs in 1-2% of air travelers with severe unilateral fronto-orbital pain lasting <30 minutes, typically during descent, caused by sinus barotrauma affecting trigeminal nerve endings in ethmoidal sinuses 1
• AHA has male predominance, occurs ages 25-30, presents with jabbing/stabbing/pulsating pain without accompanying symptoms 1
• Treatment: NSAIDs, analgesics, or triptans for prophylaxis; Valsalva maneuver, compression of pain region, chewing, or yawning for acute relief 1

Ocular Surface and Refractive Causes

• Dry eye from air travel causes forehead discomfort, severe pain, headaches, itching, and eye watering due to low cabin humidity and reduced oxygen tension 1
• Refractive error-associated headache (HARE) presents with frontal headache occurring near end of day, worsening with near work, more severe with high refractive error 3
• Convergence insufficiency or accommodative spasm causes frontal headache with diplopia, strabismus, worse with near work, may follow head trauma 3

Primary Headache Disorders with Ocular Features

• Migraine can cause eye pain, photophobia, visual aura, and forehead pressure—but hypersalivation during episodes suggests seizure activity rather than migraine 4, 5
• Migraine may present with monocular or binocular visual disturbances, autonomic features, and anisocoria 5

Increased Intracranial Pressure

• Idiopathic intracranial hypertension presents with headache (often worse in upright position), transient visual obscuration, sixth nerve palsy, and papilledema 1, 6
• Neuroimaging shows empty/partially empty sella, optic nerve tortuosity, enlarged optic nerve sheath, flattened posterior globe, and transverse sinus stenosis 1

Orbital and Neuro-Ophthalmic Causes

• Orbital trauma causes diplopia in 58-68% of blowout fractures, with forehead/eye pain, restricted eye movements, and possible oculocardiac reflex if muscle entrapped 1
• Cranial neuropathies (particularly sixth nerve palsy) cause eye discomfort, diplopia, and compensatory head posture 1

Management Algorithm

Step 1: Emergency Exclusion (Perform Immediately)

1. Measure IOP bilaterally 1, 2
2. If IOP >21 mmHg or clinical suspicion for angle closure:
   • Initiate immediate medical therapy: topical beta-blockers, alpha-agonists, carbonic anhydrase inhibitors (topical/oral/IV), parasympathomimetics, hyperosmotic agents 1
   • Perform laser peripheral iridotomy as soon as cornea clears 1, 2
   • Treat fellow eye prophylactically as 50% risk of acute attack within 5 years 2

Step 2: Risk Factor Assessment for Angle Closure

• Female gender, Asian/Inuit ethnicity, age >50, family history of angle-closure glaucoma 2
• Hyperopia, shallow anterior chamber, short axial length, thick anteriorly positioned lens 2
• Do not dilate pupils until after iridotomy if occludable angles suspected 2

Step 3: Context-Specific Evaluation

If recent air travel:

• Treat as sinus barotrauma with NSAIDs/analgesics 1
• Address dry eye with lubricants 1

If symptoms worse with near work, end of day:

• Perform refraction and assess for convergence insufficiency 3
• Treat HARE with corrective lenses; CI may require prisms, orthoptic exercises, or eye drops 3

If papilledema present:

• Obtain neuroimaging (MRI brain with contrast) 1
• Lumbar puncture to measure opening pressure if imaging shows features of raised ICP 1

If orbital trauma history:

• CT imaging to assess for fracture and muscle entrapment 1
• Check for oculocardiac reflex (bradycardia, nausea, vomiting) requiring urgent surgical intervention 1

Critical Pitfalls to Avoid

• Never dismiss transient symptoms of forehead pressure with halos/blurred vision as benign—these represent warning episodes before potentially blinding acute angle-closure attacks 2
• Do not delay fellow eye prophylaxis after treating one eye for angle closure, as acute attacks can occur within days 2
• Avoid pupil dilation in patients with suspected occludable angles until after iridotomy, as dilation can precipitate acute crisis 2
• Do not attribute all forehead pressure to sinusitis without measuring IOP and performing gonioscopy 1
• Recognize that 18% of eyes become blind within 4-10 years following untreated acute angle-closure crisis 2