What is the best course of action for a patient with no prior history of stroke, presenting with increased headaches, optic headaches, and memory issues?

Urgent Neuroimaging and Stroke Exclusion Required

This patient requires immediate brain MRI to exclude stroke, intracranial hemorrhage, mass lesion, or other serious pathology before attributing symptoms to benign causes. The combination of increased headaches, visual symptoms ("optic headaches"), and memory impairment demands urgent evaluation to rule out life-threatening conditions, even without prior stroke history 1.

Immediate Diagnostic Workup

Priority 1: Exclude Stroke and Serious Pathology

• Brain MRI is superior to CT for investigating cognitive impairment with headache and should be obtained urgently 1.
• Indications for immediate neuroimaging in this patient include: new onset neurological symptoms (memory issues), headache with cognitive decline, and age-appropriate stroke risk assessment 1.
• Critical red flags to assess: focal neurological deficits (motor weakness, sensory loss, speech disturbance, visual field defects, ataxia), altered mental status, fever, or signs of increased intracranial pressure 1, 2.

Priority 2: Rule Out Dangerous Headache Causes

The evaluation must exclude 1:

• Intracranial hemorrhage (subarachnoid or parenchymal)
• Cerebral venous sinus thrombosis (especially if patient has prothrombotic risk factors)
• Aseptic or septic meningitis
• Mass lesion or brain tumor
• Vasculitis or reversible cerebral vasoconstriction syndrome

Essential Initial Testing

Obtain immediately 1:

• Complete blood count with platelets
• Metabolic panel including glucose and renal function
• Coagulation studies (PT/INR, aPTT)
• Electrocardiogram
• Blood pressure measurement (hypertension is a critical stroke risk factor)

Differential Diagnosis Considerations

If Imaging Shows No Acute Pathology

Consider these diagnoses only after excluding stroke 1:

Vascular Cognitive Impairment:

• MRI may reveal white matter lesions or covert brain infarcts suggesting chronic cerebrovascular disease 1.
• Even without prior clinical stroke, silent infarcts increase future stroke risk and can cause progressive cognitive decline 1.

Migraine-Related Symptoms:

• Migraine with aura can mimic stroke and cause memory complaints, but diagnosis requires excluding true cerebrovascular disease first 1, 3.
• Critical distinction: Migraine aura typically has gradual onset (spreading over 5-20 minutes), while stroke symptoms are sudden 3.
• Approximately 2% of patients evaluated for stroke have migraine as final diagnosis, but 18% of stroke mimics treated with thrombolytics were migraines—emphasizing the importance of accurate diagnosis 3.

Transient Global Amnesia (TGA):

• TGA presents with isolated acute memory impairment without other focal deficits 4, 2, 5.
• Key distinguishing features: TGA patients have no motor weakness, sensory loss, speech problems, or visual field defects—only memory impairment 2, 5.
• This patient's "optic headaches" and chronic progressive symptoms make TGA unlikely, as TGA resolves within 24 hours 4, 2.

Management Algorithm Based on Findings

If Stroke or TIA Confirmed:

Immediate actions 1:

• Admit for stroke unit care
• Initiate antiplatelet therapy (aspirin 325mg loading dose, then maintenance dosing)
• High-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg)
• Blood pressure management per stroke guidelines
• Cardiac monitoring for atrial fibrillation
• Carotid imaging if not already completed

If Vascular Cognitive Impairment Identified:

Treatment priorities 1:

• Aggressive blood pressure control: Target <140/90 mmHg, consider <120 mmHg systolic if multiple vascular risk factors present 1.
• Antiplatelet therapy: Aspirin 81-325mg daily for secondary stroke prevention if brain infarcts present 1.
• Statin therapy: High-intensity statin regardless of baseline cholesterol 1.
• Consider cholinesterase inhibitors (donepezil, rivastigmine, or galantamine) for symptomatic cognitive treatment 1.

If Benign Headache Without Structural Pathology:

Only after comprehensive imaging excludes serious causes 1:

• Treat headache according to type (tension, migraine, etc.)
• Address cardiovascular risk factors
• Monitor for development of new neurological symptoms

Critical Pitfalls to Avoid

Most dangerous error: Attributing symptoms to benign headache or "stress" without neuroimaging, missing stroke or mass lesion 2, 3.

Second major pitfall: Misdiagnosing TIA as migraine or vice versa 2, 5. TIA requires urgent stroke workup within 24-48 hours and aggressive secondary prevention, while migraine does not increase stroke risk and requires no antiplatelet therapy 2, 5.

Third pitfall: Failing to recognize that cognitive symptoms with headache warrant brain imaging, especially in patients with vascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, age >60) 1.

Follow-Up Strategy

• If initial workup negative, consider repeat neuroimaging in 3-6 months if symptoms persist or worsen 1.
• Formal neuropsychological testing if cognitive complaints continue despite negative imaging 1.
• Aggressive cardiovascular risk factor modification regardless of imaging findings 1.

The bottom line: This patient needs urgent brain MRI and comprehensive stroke risk assessment before any reassurance can be provided. Memory impairment combined with headache changes represents a neurological emergency until proven otherwise 1.