What is the appropriate diagnosis and management for a 30-year-old female with persistent right-sided headaches and significant joint pain in her hands, which started with headaches and progressed to joint pain over a few months?

Diagnostic Approach: Systemic Lupus Erythematosus with CNS Involvement

This 30-year-old woman presenting with new-onset unilateral headaches followed by polyarticular hand joint pain requires urgent evaluation for systemic lupus erythematosus (SLE) with potential CNS involvement, including cerebral venous thrombosis. 1

Immediate Diagnostic Workup

Obtain urgent non-contrast head CT with CT venography to evaluate for cerebral venous thrombosis, as the combination of new headache with systemic symptoms (joint pain) lowers the threshold for neuroimaging even without focal neurological signs. 1 This is critical because:

• Young women with new headache and polyarticular joint pain are at risk for SLE with CNS involvement, which can cause headaches through multiple mechanisms including cerebral venous thrombosis 1
• The right-sided, persistent nature of the headache combined with systemic symptoms represents a "red flag" that warrants immediate imaging 2
• CT venography specifically evaluates for venous thrombosis, which can present with unilateral headache and is a known complication of SLE 1

Laboratory Evaluation

Order the following serologic tests immediately:

• Complete blood count with differential (looking for cytopenias) 1
• Comprehensive metabolic panel 1
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 1
• Antinuclear antibody (ANA) panel 1
• Anti-double stranded DNA and anti-Smith antibodies 1
• Complement levels (C3, C4) 1
• Antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti-beta-2-glycoprotein I) 1

The combination of headache and inflammatory joint pain in a young woman makes SLE a primary diagnostic consideration, and these tests will establish or exclude this diagnosis. 1

Initial Management While Awaiting Results

Start NSAIDs immediately (ibuprofen 400-600 mg or naproxen 500 mg) as they serve a dual purpose of treating both headache and inflammatory joint pain. 1 This provides symptomatic relief while diagnostic workup proceeds.

Do not start corticosteroids until infectious causes are excluded and only after consultation with rheumatology, even though empiric corticosteroids (prednisone 40-60 mg daily) can rapidly improve symptoms in inflammatory conditions. 1 Starting steroids prematurely can mask infection and complicate diagnosis.

Avoid opioids entirely as they do not address underlying inflammation and risk medication overuse headache. 3

If Cerebral Venous Thrombosis is Confirmed

Initiate anticoagulation immediately, even in the presence of hemorrhagic transformation, as recommended by the American Heart Association. 1 This is a critical management decision that can be life-saving.

Rheumatology Consultation

Obtain urgent rheumatology consultation (within 24-48 hours) given the high suspicion for SLE with potential CNS involvement. 1 The rheumatologist will guide:

• Interpretation of serologic studies 1
• Decision regarding empiric corticosteroid therapy 1
• Long-term immunosuppressive management if SLE is confirmed 4
• Consideration of methotrexate or other disease-modifying agents for joint symptoms 4

Common Pitfalls to Avoid

Do not dismiss this as primary migraine simply because the headache is unilateral. While migraine can present with unilateral, throbbing pain 2, the subsequent development of significant polyarticular joint pain indicates a systemic inflammatory process that requires investigation for secondary causes. 1, 5

Do not delay imaging waiting for laboratory results. The neuroimaging should be obtained urgently given the combination of new headache with systemic symptoms. 1, 3

Do not use screening tools like ID-Migraine or MS-Q in this context, as these are designed for primary headache disorders, not for patients with concerning systemic symptoms. 2

If Initial Workup is Negative

If CT venography and initial serologic studies are negative but clinical suspicion remains high:

• Consider MRI brain with and without contrast for more sensitive evaluation of CNS involvement 2
• Repeat ANA and specific antibody testing in 4-6 weeks, as serologies can initially be negative in early SLE 1
• Maintain close follow-up with rheumatology regardless of initial test results 1

Monitoring and Follow-up

Instruct the patient to maintain a headache diary tracking frequency, severity, associated symptoms, and medication use. 3 However, this is secondary to the urgent diagnostic evaluation.

Schedule follow-up within 1 week to review imaging and laboratory results, adjust treatment based on findings, and ensure appropriate specialist involvement. 3