What is the appropriate workup for a patient presenting with headache and blurred vision?

Workup for Headache and Blurred Vision

Immediate neuroimaging with MRI brain (with and without contrast) is the priority workup for any patient presenting with headache and blurred vision, as this combination represents a red flag for serious intracranial pathology including tumors, increased intracranial pressure, and vascular disorders. 1, 2, 3

Critical Red Flag Assessment

This presentation demands urgent evaluation because blurred vision combined with headache suggests:

• Increased intracranial pressure (papilledema, mass lesion, idiopathic intracranial hypertension) 1
• Acute angle-closure glaucoma (especially if accompanied by eye pain, halos around lights, mid-dilated pupil) 1
• Intracranial mass or tumor (particularly if progressive symptoms) 1, 4
• Cerebral venous thrombosis (cortical vein or dural sinus thrombosis) 1
• Optic neuritis or uveitis (if unilateral with eye pain) 1, 5

Essential Physical Examination Elements

Before or concurrent with imaging, perform these specific examinations:

• Fundoscopic examination to identify papilledema, optic disc swelling, or venous engorgement—critical for detecting increased intracranial pressure 1, 4
• Pupil examination for size, shape (mid-dilated/oval suggests acute angle closure), reactivity, and relative afferent pupillary defect 1
• Visual acuity testing and visual field assessment by confrontation 1
• Intraocular pressure measurement if acute angle-closure glaucoma suspected (symptoms include halos, severe eye pain, corneal edema) 1, 6
• Complete neurologic examination including cranial nerves, motor/sensory function, gait, and reflexes to identify focal deficits 1, 7
• Slit-lamp examination if available, to evaluate for anterior chamber inflammation, corneal edema, or other anterior segment pathology 1, 6

Neuroimaging Protocol

MRI brain with and without gadolinium contrast is the preferred initial imaging modality because it:

• Provides superior detection of structural lesions, tumors, demyelination, and vascular abnormalities without radiation 1, 3
• Better visualizes optic nerve pathology, empty sella, dilated optic sheaths, and posterior globe flattening (signs of increased intracranial pressure) 1
• More sensitive than CT for detecting isodense tumors and meningeal infiltration 1

CT head without contrast may substitute only if MRI unavailable or contraindicated, though it is less sensitive for many critical diagnoses 3

Additional imaging considerations:

• MR venography (MRV) or CT venography if cerebral venous thrombosis suspected (progressive headache, seizures, focal deficits, or dural enhancement on initial imaging) 1
• Orbital imaging with fat-saturated T2 sequences if optic nerve pathology or orbital process suspected 1
• Digital subtraction angiography may be needed if venous thrombosis suspected but not confirmed on noninvasive imaging 1

Urgent Ophthalmology Referral Indications

Refer immediately to ophthalmology if:

• Papilledema identified on fundoscopy (risk of permanent vision loss) 1
• Acute angle-closure suspected (mid-dilated pupil, corneal edema, very high IOP, severe eye pain) 1
• Uveitis or inflammatory eye disease (eye pain, photophobia, anterior chamber cells) 1, 6
• Progressive or sudden vision loss of any etiology 1

Laboratory Testing (Secondary Priority)

Laboratory work is less revealing than neuroimaging for this presentation but should include: 3, 8

• ESR and CRP if patient >50 years old (to exclude giant cell arteritis, which causes vision loss and headache) 1, 8
• Basic metabolic panel (glucose, sodium, renal function) 3, 8
• Complete blood count 8
• Thyroid function tests (TSH, free T4) 8

Additional labs if specific diagnoses suspected:

• Lumbar puncture with opening pressure measurement if imaging shows no mass effect but increased intracranial pressure suspected (papilledema present, suspicion for idiopathic intracranial hypertension, meningitis, or carcinomatous meningitis) 1
• Bartonella henselae serology if optic disc swelling with macular star pattern and cat exposure 5
• ACE level and chest imaging if granulomatous uveitis with elevated IOP 6

Age-Specific Considerations

For patients >50 years old with new-onset headache and vision changes:

• This age group has fundamentally higher risk of serious pathology (tumor, stroke, subdural hematoma, giant cell arteritis) 2, 3
• Neuroimaging is mandatory, not optional, even with normal neurologic examination 2, 3
• Check ESR/CRP immediately if any temporal tenderness, jaw claudication, or scalp pain present (giant cell arteritis can cause irreversible blindness) 1, 8

For younger patients:

• Still requires neuroimaging given the red flag combination of symptoms 2, 7
• Consider idiopathic intracranial hypertension (especially in overweight females of childbearing age) 1
• Acute angle-closure can occur in hyperopic eyes regardless of age 1

Common Diagnostic Pitfalls

• Assuming "migraine with aura" without fundoscopic examination—missing papilledema leads to delayed diagnosis of increased intracranial pressure and permanent vision loss 1, 4
• Attributing symptoms to post-lumbar puncture headache when dural enhancement may actually indicate cortical vein thrombosis 1
• Ordering only laboratory tests without neuroimaging—structural causes are far more likely than metabolic derangements in this presentation 3, 7
• Delaying ophthalmology referral when acute angle-closure present (irreversible optic nerve damage occurs rapidly with untreated high IOP) 1
• Missing bilateral sixth nerve palsy as sign of increased intracranial pressure 1