What are the recommended steps for managing generalized headache and bilateral blurred vision?

Management of Generalized Headache and Bilateral Blurred Vision

Immediate Priority: Rule Out Vision-Threatening and Life-Threatening Causes

This presentation demands urgent ophthalmologic evaluation and measurement of intraocular pressure (IOP) to exclude acute angle-closure glaucoma, which can present with generalized headache, bilateral blurred vision, halos around lights, and elevated IOP (40-50 mmHg), and requires immediate treatment to prevent permanent vision loss 1, 2.

Critical Red Flags Requiring Emergency Evaluation

• Measure IOP immediately - Acute angle-closure presents with severely elevated IOP (>40 mmHg), mid-dilated poorly reactive pupils, corneal edema, and conjunctival hyperemia 1
• Assess for papilledema - Bilateral optic disc swelling suggests idiopathic intracranial hypertension (IIH), which presents with headache, bilateral blurred vision, transient visual obscurations, and pulsatile tinnitus 1, 3, 4
• Check visual acuity and visual fields - Progressive visual field loss indicates urgent need for IOP-lowering treatment or CSF pressure reduction 1
• Perform gonioscopy - Iridocorneal contact on gonioscopy confirms angle-closure disease requiring immediate intervention 1

Differential Diagnosis Algorithm

If IOP >21 mmHg with narrow angles on gonioscopy:

• Diagnose acute angle-closure glaucoma
• Initiate immediate IOP-lowering therapy (topical beta-blockers, alpha-agonists, carbonic anhydrase inhibitors, hyperosmotic agents) 1
• Arrange urgent laser peripheral iridotomy within 24-48 hours 1
• Treat fellow eye prophylactically as 88-89% risk of acute closure 1

If papilledema present with normal neuroimaging:

• Perform lumbar puncture to measure opening pressure (>25 cm H₂O confirms IIH) 1, 3
• Initiate acetazolamide for CSF pressure reduction 1, 3
• Refer to neuro-ophthalmology for serial visual field monitoring 1
• Consider surgical intervention (optic nerve sheath fenestration or CSF shunting) if vision deteriorating despite medical therapy 1

If anterior uveitis present (cells, Tyndall phenomenon, keratic precipitates):

• Secondary open-angle glaucoma from granulomatous uveitis can cause elevated IOP with headache and blurred vision 2
• Check ACE, soluble IL-2 receptor, chest imaging for sarcoidosis 2
• Initiate topical and systemic corticosteroids 2

Migraine Management If Vision-Threatening Causes Excluded

Only after excluding acute angle-closure glaucoma, IIH, and other secondary causes should migraine treatment be initiated 5, 6.

First-Line Acute Treatment

• NSAIDs as initial therapy: Naproxen sodium 500-825 mg or ibuprofen 400-800 mg at headache onset while pain still mild 5, 6
• Add metoclopramide 10 mg 20-30 minutes before NSAID for synergistic analgesia and to address nausea 5, 6
• Escalate to triptan if NSAIDs fail: Sumatriptan 50-100 mg or rizatriptan 10 mg for moderate-to-severe attacks 5, 6
• Combination therapy superior: Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides 130 more patients per 1000 achieving sustained relief at 48 hours compared to either alone 5, 6

Critical Frequency Limitation

Restrict all acute migraine medications to maximum 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 5, 6. If requiring acute treatment more than twice weekly, immediately initiate preventive therapy 5, 6.

Parenteral Options for Severe Presentations

• IV metoclopramide 10 mg PLUS ketorolac 30 mg provides rapid relief with minimal rebound risk 5
• Prochlorperazine 10 mg IV comparable efficacy to metoclopramide with 21% adverse event rate 5
• Subcutaneous sumatriptan 6 mg achieves highest efficacy (59% pain-free at 2 hours) with 15-minute onset 5, 6

Medications to Avoid

• Never use opioids (including hydromorphone) as they cause dependency, rebound headaches, and loss of efficacy 5, 6
• Avoid ergotamine derivatives due to medication-overuse headache risk and ergot poisoning potential 1, 5

Common Pitfalls

• Delaying ophthalmologic evaluation - Acute angle-closure can cause permanent vision loss within hours if untreated; 18% of eyes become blind following acute angle-closure events 1
• Missing IIH in young obese women - Papilledema may be subtle; failure to perform funduscopy delays diagnosis and risks progressive visual field loss 1, 3, 4
• Treating presumed migraine without measuring IOP - Bilateral blurred vision with headache is NOT typical migraine and mandates IOP measurement 1, 2
• Allowing frequent acute medication use - Creates medication-overuse headache cycle; transition to preventive therapy immediately if needing treatment >2 days/week 5, 6