What is the best course of action for a 30-year-old female with a history of iron deficiency anemia and joint pain, who initially improved with prednisone (corticosteroid), but now experiences worsening headaches, particularly when lying down?

Urgent Neuroimaging Required—This is Not an Iron Deficiency Problem

This patient requires immediate brain imaging (MRI with contrast preferred, or CT if MRI unavailable) to evaluate for increased intracranial pressure, given the positional worsening of headaches after corticosteroid use. The clinical presentation—headaches that initially improved with prednisone but now worsen when lying down—is a red flag for secondary intracranial pathology, not a manifestation of iron deficiency anemia.

Critical Clinical Reasoning

Why This is NOT About Iron Deficiency

• While iron deficiency anemia can cause headaches, these are typically chronic, non-positional, and associated with fatigue rather than the acute worsening pattern described here 1, 2
• The temporal relationship with prednisone use and the specific positional component (worse lying down) point to increased intracranial pressure or mass effect, not anemia 1
• Iron deficiency headaches do not characteristically improve with corticosteroids then worsen with positional changes 2

The Prednisone Response Pattern is Concerning

• Initial improvement with prednisone suggests an inflammatory or mass lesion that temporarily responded to corticosteroids
• Subsequent worsening despite prednisone indicates either:
  • Progressive mass effect (tumor, abscess)
  • Rebound inflammation
  • Development of complications (hemorrhage, hydrocephalus)
  • Steroid-induced complications (though less likely given the timeline)

Positional Headaches Demand Immediate Action

• Headaches worse when lying down suggest increased intracranial pressure from:
  • Brain tumor (primary or metastatic)
  • Subdural hematoma
  • Cerebral venous sinus thrombosis
  • Idiopathic intracranial hypertension (though typically worse lying down in the opposite pattern)
  • Posterior fossa lesions

Immediate Management Algorithm

Step 1: Urgent Neuroimaging (Within 24 Hours)

• MRI brain with and without gadolinium contrast is the preferred study
• If MRI unavailable or contraindicated, obtain CT head with contrast
• Include MR or CT venography if cerebral venous sinus thrombosis is suspected (given joint pain history suggesting possible hypercoagulable state)

Step 2: Neurological Examination

• Assess for papilledema on fundoscopic examination
• Evaluate for focal neurological deficits
• Check for meningeal signs
• Document mental status changes

Step 3: Consider Lumbar Puncture (Only After Imaging Rules Out Mass Effect)

• If imaging shows no mass lesion and increased intracranial pressure is suspected
• Opening pressure measurement is critical
• Send CSF for cell count, protein, glucose, and cultures if infection suspected

The Iron Deficiency Management Can Wait

Once Life-Threatening Causes Are Excluded

Only after neuroimaging excludes serious intracranial pathology should you address the iron deficiency anemia:

• Initiate ferrous sulfate 200 mg once daily on an empty stomach 3
• Add vitamin C 500 mg with the iron dose to enhance absorption 4, 3
• Mandatory gastrointestinal investigation is required in a 30-year-old woman with unexplained iron deficiency anemia, as approximately one-third of patients have underlying GI pathology 4

GI Workup Components (After Neurological Emergency Excluded)

• Upper endoscopy with duodenal biopsies to exclude celiac disease (2-3% prevalence in IDA patients) 4
• Colonoscopy to exclude lower GI bleeding sources 4
• Celiac serology (tissue transglutaminase antibody) 3
• Helicobacter pylori testing and eradication if positive 3
• Detailed menstrual history given her age 1, 5

Common Pitfall to Avoid

The most dangerous error would be attributing these worsening positional headaches to iron deficiency anemia and delaying neuroimaging. The combination of corticosteroid response followed by worsening with positional component is a neurosurgical emergency until proven otherwise. Iron deficiency does not cause this clinical pattern 1, 2.

The joint pain history raises additional concern for systemic inflammatory conditions (vasculitis, connective tissue disease) or hypercoagulable states that could cause cerebral venous thrombosis—another reason urgent imaging cannot be delayed.