What is the diagnosis and management for an adult patient with no specified medical history presenting with a headache in the right frontal region, accompanied by dizziness and weakness?

Right Frontal Headache with Dizziness and Weakness: Diagnosis and Management

This presentation requires immediate emergency evaluation to rule out stroke or other life-threatening cerebrovascular events, as the combination of unilateral headache with dizziness and weakness has a 72% probability of stroke when multiple neurological deficits are present. 1, 2

Immediate Emergency Assessment

Critical First Steps in the Emergency Department

• Check bilateral radial pulses and blood pressure in both arms immediately to differentiate between stroke and acute arterial occlusion; a blood pressure difference >20 mmHg between arms confirms significant arterial compromise 2

• Perform the Cincinnati Prehospital Stroke Scale evaluating facial droop, arm drift, and speech abnormalities—if any of these three signs is abnormal, the probability of stroke is 72% 1, 2

• Assess for the "6 P's" of acute limb ischemia: Pain, Pallor, Pulselessness, Paresthesias (numbness), Poikilothermia (cool limb), and Paralysis 2

Urgent Neuroimaging (Do Not Delay)

• Brain MRI with diffusion-weighted imaging is the preferred initial imaging modality and must be performed immediately to detect acute ischemic changes 1, 2

• If MRI is unavailable, perform CT head without contrast to rule out hemorrhage, as this fundamentally changes treatment 1, 2

• Include CT angiography or MR angiography from the aortic arch to the vertex to evaluate for carotid and vertebral artery disease 1, 3

Essential Laboratory Tests

• Obtain complete blood count, basic metabolic panel, coagulation studies, blood glucose, and inflammatory markers to assess for conditions that may contribute to stroke risk 1

High-Risk Clinical Patterns to Recognize

Stroke Risk Stratification

• Patients with unilateral neurological symptoms have a 10% risk of completed stroke within the first week, with the highest risk in the first 48 hours 2

• The combination of right frontal headache with dizziness and weakness represents multiple neurological deficits, which significantly increases stroke probability 1, 2

Red Flags Requiring Immediate Action

• New, worse, worsening, or abrupt onset headache increases likelihood of secondary headache disorder requiring diagnostic testing 4

• Headache with neurologic findings and/or symptoms (dizziness and weakness in this case) mandates urgent evaluation 4

• Headache brought on by Valsalva maneuver or cough should raise concern 4

Differential Diagnosis Considerations

Primary Considerations (Life-Threatening)

• Acute ischemic stroke affecting the left hemisphere (causing right-sided symptoms) 1, 2

• Cerebral venous thrombosis should be evaluated with MR venography if conventional imaging is negative 1

• Subarachnoid hemorrhage must be ruled out with CT or CSF examination 4, 5

Secondary Considerations

• Vestibular migraine can present with headache and dizziness but typically lacks focal weakness 6

• Orthostatic hypotension presents with dizziness upon standing but would not explain focal headache or weakness 7

• Intracranial mass lesion (tumor, abscess) can cause focal headache with progressive neurological deficits 4, 5

Extended Diagnostic Workup (If Initial Imaging Negative)

• Consider electroencephalogram to rule out seizure activity, especially with transient symptoms 1

• Lumbar puncture should be performed if infectious or inflammatory CNS disease is suspected (useful for diagnosing subarachnoid bleeding, infection, and high/low CSF pressure syndromes) 1, 4

• Carotid ultrasound must be performed to identify extracranial carotid stenosis >70% requiring carotid endarterectomy 2

Management Based on Diagnosis

If Acute Ischemic Stroke is Confirmed

• Initiate dual antiplatelet therapy (aspirin + clopidogrel 75 mg) for the first 21 days in patients with symptomatic carotid stenosis not undergoing revascularization, followed by long-term single antiplatelet therapy 2

• Immediate vascular surgery consultation for thrombectomy/embolectomy is required, as outcome depends entirely on time to reperfusion 2

If Acute Arterial Occlusion is Identified

• Emergency vascular surgery consultation for thrombectomy/embolectomy must occur immediately 2, 3

If Migraine is Diagnosed (Only After Stroke Ruled Out)

• For mild to moderate migraine, use NSAIDs such as ibuprofen 400-800 mg every six hours (maximal initial dose 800 mg) or naproxen sodium 275-550 mg every 2-6 hours 7

• Adjunctive therapy with metoclopramide 10 mg IV or orally 20-30 minutes before or with analgesics can improve efficacy 7

• Consider preventive therapy if patient has more than two headaches per week to avoid medication-overuse headaches 7

Critical Pitfalls to Avoid

• DO NOT discharge the patient without neuroimaging—this combination of symptoms requires urgent brain imaging to rule out stroke 1, 2

• DO NOT attribute symptoms to benign causes (tension headache, migraine, viral illness) without first excluding cerebrovascular events 1, 2, 3

• DO NOT delay imaging for laboratory results—time to reperfusion is critical in stroke management 2

• DO NOT treat as primary headache and send home without completing the stroke workup—this is a potentially fatal error 3