Severe Headache with Vomiting and Blurry Vision: Urgent Differential Diagnosis
This patient requires immediate neuroimaging to rule out life-threatening causes of increased intracranial pressure, including posterior fossa tumor, cerebral venous sinus thrombosis, or other structural lesions causing secondary headache. 1, 2
Critical Red Flags Present in This Case
This patient exhibits multiple concerning features that mandate urgent evaluation:
- Severe headache (8/10) with vomiting occurring over consecutive days suggests increased intracranial pressure rather than benign primary headache 1, 2
- Headaches waking patient from sleep twice in one night is a classic red flag for secondary headache, particularly posterior fossa lesions or increased intracranial pressure 1, 2
- Episodes of blurry vision lasting 5-10 seconds suggest transient visual obscurations from papilledema or ocular-motor dysfunction from mass effect 3, 1
- Shifting headache location (temples but migrating) can indicate evolving pathology rather than stable primary headache pattern 2, 4
Most Likely Dangerous Diagnoses to Exclude Immediately
Primary Concerns Requiring Emergency Imaging
Increased intracranial pressure from mass lesion: The American Academy of Pediatrics recommends immediate brain imaging, preferably MRI, to rule out posterior fossa tumor or other causes of increased intracranial pressure in patients with recurrent morning headaches and vomiting before initiating treatment 1. The combination of severe headache, vomiting, nocturnal awakening, and transient visual obscurations strongly suggests this diagnosis 1, 2.
Cerebral venous sinus thrombosis (CVST): This presents with severe headache, vomiting, and visual disturbances, and can be life-threatening if not recognized 2. The shifting headache location and progressive nature over days fits this pattern 2, 4.
Vaccine-induced immune thrombocytopenia and thrombosis (VITT): If this patient received COVID-19 vaccination 5-30 days prior, VITT must be considered, as it presents with severe or unusual headaches accompanied by blurred vision, nausea and vomiting 3. VITT affects cerebral veins in 50% of cases and requires urgent recognition for life-saving management with non-heparin anticoagulation and intravenous immunoglobulin 3.
Secondary Considerations
Reversible cerebral vasoconstriction syndrome (RCVS): Can present with severe headache and visual symptoms, though typically more thunderclap in nature 2.
Idiopathic intracranial hypertension: Particularly in certain demographics, presents with headache worse when lying down, transient visual obscurations, and vomiting 3, 2.
Immediate Diagnostic Workup Required
Obtain MRI brain with and without contrast as the preferred initial imaging modality to exclude posterior fossa tumor, hydrocephalus, Chiari malformation, cerebral venous thrombosis, and other structural lesions 1. MRI is superior to CT for detecting posterior fossa lesions and venous sinus thrombosis 1, 2.
If VITT is suspected (recent COVID-19 vaccination within 5-42 days): Urgently obtain complete blood count with platelet count, D-dimer, and anti-PF4 antibody ELISA assay 3. Definite VITT requires all five criteria: onset 5-30 days post-vaccination, thrombosis, thrombocytopenia (platelets <150×10⁹/L), D-dimer >4000 μg/mL, and positive anti-PF4 antibodies 3.
Fundoscopic examination to assess for papilledema indicating increased intracranial pressure 1, 2.
Critical Pitfall to Avoid
Do not treat this as primary migraine without neuroimaging first. While migraine can present with headache, vomiting, and visual aura, the pattern of nocturnal awakening, progressive worsening over consecutive days, and transient (not typical aura-pattern) visual disturbances strongly suggests secondary headache 1, 2, 4. The American Academy of Neurology recommends evaluating if the headache pattern is different from the patient's usual attacks and identifying "red flags" such as change in headache pattern, which requires neuroimaging before treating as primary migraine 5.
If Imaging is Normal: Consider Primary Headache Subtypes
Only after dangerous secondary causes are excluded should primary headache be considered:
Migraine with aura: The blurred vision could represent visual aura, and migraine commonly presents with nausea, vomiting, and severe pain 3, 5. However, typical migraine aura lasts 5-60 minutes, not 5-10 seconds 3.
Ocular-motor subtype of concussion (if recent head trauma): Presents with difficulty with visual activities, blurred vision, frontal headaches, and vision-derived nausea 3. However, this requires a history of head injury 3.
Treatment Considerations Only After Imaging
If imaging excludes dangerous pathology and primary migraine is diagnosed, the American Headache Society recommends starting treatment with triptans (sumatriptan 100 mg oral) combined with naproxen sodium 500 mg, plus an antiemetic (metoclopramide 10 mg) administered 20-30 minutes before analgesics 5, 6. However, all acute migraine medications must be strictly limited to no more than 2 days per week to prevent medication-overuse headache 5, 6.