What are the immediate, short-term, and long-term management plans for a patient presenting with headache and right eye pain?

Management Plan for Headache with Right Eye Pain

Immediate Management (First 24 Hours)

The immediate priority is to rule out acute angle-closure crisis (AACC), which constitutes a medical emergency requiring treatment within hours to prevent permanent vision loss. 1

Emergency Assessment and Red Flag Evaluation

• Measure intraocular pressure (IOP) immediately in both eyes, as AACC presents with very high IOP, eye pain, headache, nausea, corneal edema, and mid-dilated poorly reactive pupil 1
• Evaluate for thunderclap headache (sudden onset peaking within 1 minute), which suggests subarachnoid hemorrhage requiring urgent neuroimaging 2
• Assess for fever or signs of infection, which necessitate urgent evaluation for meningitis or encephalitis 3, 2
• Perform complete neurologic examination looking for focal deficits, motor weakness, or abnormal findings that mandate immediate imaging 3, 2
• Check for headache worsened by Valsalva maneuver (coughing, straining, bending), suggesting increased intracranial pressure 3, 2

Immediate Ophthalmic Examination

• Perform gonioscopy to assess for iridocorneal angle closure, as primary angle-closure disease can present with headache and eye pain 1
• Examine pupil size, shape (may be mid-dilated, asymmetric, or oval in AACC), and reactivity (may be poor or nonreactive) 1
• Assess for conjunctival hyperemia, corneal edema (microcystic and stromal edema common in acute cases), and anterior chamber inflammation 1
• Evaluate for relative afferent pupillary defect, which may indicate asymmetric optic nerve damage or elevated IOP 1

Immediate Treatment if AACC Confirmed

• Initiate immediate IOP-lowering therapy to prevent glaucomatous optic neuropathy, which can develop rapidly with untreated high IOP 1
• Refer urgently to ophthalmology for definitive treatment, as 18% of eyes become blind following AACC, with 50% of blindness due to glaucoma 1
• Treat the fellow eye prophylactically, as untreated fellow phakic eyes are at increased risk for developing acute angle closure 1

Immediate Management if Primary Headache Suspected

• Administer acute migraine treatment with NSAIDs, acetaminophen, or triptans if no contraindications exist 1, 4
• Consider subcutaneous sumatriptan for rapid onset of action if severe migraine with nausea/vomiting 1
• Avoid triptans in patients with cardiovascular disease due to vasoconstrictive properties 1, 4
• Consider intranasal dihydroergotamine (DHE) as alternative acute therapy 1

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Short-Term Management (1-4 Weeks)

Diagnostic Clarification

• Obtain MRI brain if any red flags present: new headache after age 50, progressively worsening pattern, abnormal neurologic examination, or atypical features 3, 2
• Maintain headache diary tracking frequency, severity, triggers, and treatment response to guide diagnosis 3
• Assess for medication overuse headache if analgesics used >10 days per month 5

Ophthalmic Follow-Up if AACC Treated

• Monitor retinal nerve fiber layer thickness, which increases in first few days, returns to average at 1 month, and decreases at 3 months due to axonal swelling then atrophy 1
• Assess visual function preservation and quality of life as primary outcome criteria 1
• Evaluate fellow eye for prophylactic treatment to reduce risk of bilateral blindness 1

Primary Headache Management

• Classify headache type based on International Headache Society criteria: chronic migraine (≥15 headache days/month for >3 months with migraine features on ≥8 days), episodic migraine (<15 days/month), cluster headache, or tension-type headache 2
• Identify and avoid personal triggers through diary analysis 3
• Establish regular sleep patterns and consider stress management techniques 3

Acute Treatment Optimization

• Trial gepants (rimegepant or ubrogepant) if triptans contraindicated or ineffective, which eliminate headache in 20% at 2 hours with nausea/dry mouth in 1-4% 4
• Consider lasmiditan (5-HT1F agonist) for patients with cardiovascular risk factors, as it appears safe in this population 4
• Limit acute therapy to no more than 2 times per week to prevent medication-overuse headache 1

Specialist Referral Indications

• Refer to neurology immediately for cluster headaches, headache with motor weakness, or migraine with persistent aura 3, 5
• Refer for uncertain diagnosis after thorough evaluation or poor response to preventive strategies 5
• Refer chronic migraine (≥15 headache days/month) for specialized treatments 5

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Long-Term Management (>1 Month)

Preventive Therapy Initiation

• Consider prophylaxis if headaches occur more than twice weekly, with evidence-based options including topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate 3
• Topiramate is the only agent with proven efficacy in randomized controlled trials for chronic migraine 2
• OnabotulinumtoxinA is the only FDA-approved therapy for chronic migraine prophylaxis 3, 2
• Preventive treatments reduce migraine by 1-3 days per month relative to placebo 4

Topiramate Monitoring (If Prescribed)

• Measure baseline and periodic serum bicarbonate to monitor for metabolic acidosis 6
• Monitor for serious eye problems including acute myopia and secondary angle-closure glaucoma, which can lead to blindness if untreated 6
• Watch for decreased sweating and increased body temperature, especially in hot weather 6
• Assess for cognitive effects including confusion, problems with concentration, attention, memory, and speech 6
• Monitor for hyperammonemia if co-administered with valproic acid, which can affect mental activities and decrease alertness 6
• Ensure adequate hydration to prevent kidney stones, as topiramate is a carbonic anhydrase inhibitor that promotes stone formation 6

Ongoing Monitoring and Adjustment

• Reassess treatment response every 3-4 months, as neuromodulators require this duration at therapeutic dose to show pain reduction 1
• Evaluate for comorbid anxiety, depression, or mood disorders requiring multidisciplinary management 1
• Consider complementary therapies including acupuncture, cognitive behavioral therapy, or hypnosis for holistic management 1

Quality of Life Preservation

• The primary outcome criteria are preservation of visual function, maintenance of quality of life, and reduction of risk of acute complications 1
• Repatriate stable patients from specialist care once diagnosis established and effective treatment plan in place 5
• React promptly to any change in headache pattern warranting re-evaluation or re-referral 5

Common Pitfalls to Avoid

• Do not dismiss headache in patients over 50 as "just migraine" without thorough evaluation for secondary causes including temporal arteritis 5
• Avoid opioids for regular headache management due to risk of dependency and rebound headaches 3
• Do not delay treatment of suspected AACC for diagnostic procedures, as sight loss occurs almost exclusively before treatment initiation 1
• Recognize that primary headache disorders can cause eye pain without ocular pathology, but always rule out ophthalmic emergencies first 7, 8