What is the differential diagnosis and appropriate workup for an elderly female patient with a history of hypertension and migraines, presenting with a severe headache and chest pain, described as a pressure sensation behind the left eye and on the side of the head with intermittent stabbing pain, accompanied by sharp and localized left-sided chest pain?

Differential Diagnosis and Workup for Severe Headache with Chest Pain in Elderly Hypertensive Female

This elderly woman with hypertension presenting with severe, atypical headache and concurrent chest pain requires immediate evaluation for acute coronary syndrome (ACS) and hypertensive emergency, as women ≥75 years are systematically underdiagnosed for cardiac events and age itself is a major independent risk factor. 1, 2

Life-Threatening Differential Diagnoses (Priority Order)

Acute Coronary Syndrome

• ACS must be the primary consideration in this elderly woman, as traditional risk scores underestimate cardiac risk in elderly women by up to 50% and physicians frequently misclassify their symptoms as noncardiac 1, 2
• The concurrent chest pain described as "sharp and localized" does NOT exclude ACS—women >75 years commonly present with accompanying symptoms rather than isolated typical anginal pain, including jaw/neck pain, back pain, epigastric symptoms, and atypical chest discomfort 3, 1, 2
• Her hypertension significantly elevates risk (66.6% of women with ACS have hypertension in the PROMISE trial) 1
• The headache itself may represent referred pain or autonomic symptoms associated with cardiac ischemia, as women present with more diverse symptom patterns than men 2

Hypertensive Emergency with Encephalopathy

• Severe sustained hypertension can cause severe headache, particularly when blood pressure rises rapidly 4, 5, 6
• Hypertensive encephalopathy presents with headache (often pressure-like), visual disturbances, and can progress to somnolence, seizures, and loss of consciousness 3
• The rate of BP increase is more important than absolute BP value in development of hypertensive emergencies 3
• Posterior reversible encephalopathy syndrome (PRES) causes white matter lesions in posterior brain regions that are fully reversible with timely recognition 3

Aortic Dissection

• Sudden-onset tearing or ripping chest pain with radiation to upper or lower back is classic, but headache as initial manifestation can occur in patients with hypertension 3, 7
• The "pressure sensation behind left eye" combined with chest pain in a hypertensive patient warrants consideration 7
• Absence of typical "ripping" quality does NOT exclude dissection 7

Other Life-Threatening Causes

• Pulmonary embolism presents with acute chest pain and dyspnea 8
• Acute angle-closure glaucoma can cause severe periorbital headache with eye pain 3

Non-Life-Threatening Differential Diagnoses

Migraine Variant

• The patient describes this as "distinct from typical migraines," making this less likely as primary diagnosis 3
• However, hypertension may transform episodic migraine into chronic daily headache and increase frequency/severity 4, 5, 6
• Migraine and hypertension share common mechanisms including endothelial dysfunction 6

Musculoskeletal Chest Pain

• Chest wall pain is reproducible with palpation and worsens with specific movements 3, 8
• However, this would NOT explain the severe headache 8

Gastroesophageal Reflux Disease

• Can mimic cardiac symptoms with epigastric pain, but would not explain headache or periorbital pressure 1, 8, 2

Immediate Diagnostic Workup (Within 10 Minutes)

Mandatory Initial Tests

• 12-lead ECG within 10 minutes to assess for ST-elevation MI, ST depression, or new T-wave inversion 3, 1, 2
• Blood pressure measurement in both arms and lower limb to detect pressure differences from aortic dissection 3
• Cardiac troponin measurement as soon as possible if ACS suspected 3, 1, 2
• Fundoscopy to assess for papilledema (hypertensive emergency) or retinal hemorrhages (malignant hypertension) 3

Laboratory Analysis

• Hemoglobin, platelet count 3
• Creatinine, sodium, potassium, lactate dehydrogenase (LDH), haptoglobin 3
• Quantitative urinalysis for protein, urine sediment for erythrocytes, leucocytes, cylinders and casts (to assess for hypertensive nephropathy) 3
• Troponin-T, CK, CK-MB 3
• Peripheral blood smear if thrombotic microangiopathy suspected 3

Imaging Studies

Immediate (Emergency Department):

• CT head without contrast to exclude intracranial hemorrhage, mass lesion, or findings of hypertensive encephalopathy 3
• MRI brain with FLAIR imaging if hypertensive encephalopathy suspected—shows increased signal intensity on T2-weighted imaging in posterior regions 3
• Chest X-ray to assess for pulmonary edema, aortic contour abnormalities 3
• CT angiography of chest if aortic dissection suspected based on clinical presentation or BP differential between arms 3

On Indication:

• Transthoracic echocardiography or point-of-care cardiac ultrasound to assess cardiac structure, function, and pulmonary edema 3
• Renal ultrasound if concern for postrenal obstruction or to assess kidney size 3

Critical Focused History Elements

Headache Characteristics to Elicit

• Exact time of onset and progression pattern 3
• Any focal neurological symptoms (somnolence, visual changes, weakness, seizures) suggesting hypertensive encephalopathy 3
• Presence of nausea, vomiting (common with both ACS and hypertensive emergency) 3

Cardiac Symptom Assessment

• Emphasize accompanying symptoms more common in elderly women with ACS: shortness of breath, diaphoresis, palpitations, jaw/neck pain, back pain, epigastric discomfort, nausea, lightheadedness, syncope, or unexplained falls 3, 1, 2
• Precipitating factors (exertion, emotional stress) 3
• Any prior episodes of similar symptoms 3

Medication History

• Current antihypertensive medications and adherence 3
• Recent medication changes or withdrawal 3
• Use of NSAIDs, steroids, sympathomimetics, or other drugs that can precipitate hypertensive crisis 3

Physical Examination Focus

Cardiovascular Examination

• Blood pressure in both arms and one leg (>20 mmHg difference suggests aortic dissection) 3
• Cardiac auscultation for murmurs (aortic regurgitation in dissection, new murmurs in ACS complications) 3
• Assessment for signs of heart failure (elevated JVP, pulmonary rales, peripheral edema) 3
• Peripheral pulses and vascular examination 3

Neurological Examination

• Level of consciousness and mental status 3
• Focal neurological deficits (rare in hypertensive encephalopathy but should raise suspicion for stroke or hemorrhage) 3
• Visual field testing 3

Chest Wall Examination

• Palpation to assess for reproducible chest pain (suggests musculoskeletal cause but does NOT exclude cardiac disease) 3

Critical Pitfalls to Avoid

• Never assume symptoms are noncardiac based on "atypical" presentation—what is considered "atypical" is based on male symptom patterns, and elderly women are systematically underdiagnosed 1, 2
• Do not rely on nitroglycerin response as diagnostic criterion—esophageal spasm and GERD also respond to nitroglycerin 3, 8, 2
• Do not delay urgent transport to emergency department if initially evaluated in office setting—activate 9-1-1 for EMS transport 3, 2
• Do not attribute symptoms to anxiety or migraine variant until comprehensive cardiac and hypertensive emergency workup is negative 2
• Do not assume focal neurological lesions are absent in hypertensive encephalopathy—their presence should raise suspicion for intracranial hemorrhage or ischemic stroke 3

Immediate Management Considerations

If ACS Suspected

• Aspirin (chewable or water-soluble) as soon as possible unless contraindicated 3
• Oxygen if hypoxemic 3
• Pain relief with opiates if needed 3
• Continuous cardiac monitoring 3

If Hypertensive Emergency Confirmed

• Blood pressure lowering treatment should be initiated promptly but controlled (avoid precipitous drops) 3
• Target BP reduction of 10-15% in first hour, then gradual reduction over 24-48 hours 3

Transport Decision

• Immediate EMS transport to emergency department for any suspected life-threatening cause 3, 2
• Do not delay for additional testing in office setting 2