What is the appropriate initial evaluation and management for a 22-year-old male presenting with pressure around the lateral corner of one eye and headache?

Initial Evaluation for 22-Year-Old Male with Lateral Eye Pressure and Headache

This presentation most likely represents migraine with trigeminal autonomic features rather than a primary ocular or sinus disorder, and should be evaluated with a focused history for migraine characteristics and red flags before considering imaging or ophthalmologic referral. 1, 2

Immediate Red Flag Assessment

First, rapidly screen for features requiring urgent neuroimaging or specialist evaluation:

• Thunderclap onset (sudden peak within 1 minute) suggesting subarachnoid hemorrhage 2
• Focal neurological deficits or motor weakness necessitating immediate imaging 1, 2
• Abnormal neurological examination findings mandating urgent evaluation 1, 2
• Progressively worsening pattern over days to weeks suggesting evolving pathology 1, 2
• Headache awakening from sleep indicating possible increased intracranial pressure 3, 2
• Fever or signs of infection requiring urgent meningitis evaluation 2

If any red flags are present, obtain MRI brain (preferred modality) immediately. 1, 2

Focused History for Primary Headache Diagnosis

Pain Characteristics to Elicit

Location and laterality: Unilateral periorbital pain lasting 15-180 minutes with restlessness suggests cluster headache, while bilateral or unilateral pain lasting 4-72 hours with preference to lie still suggests migraine. 4, 3

Associated autonomic symptoms: The presence of ipsilateral lacrimation, conjunctival injection, nasal congestion, rhinorrhea, eyelid edema, or ptosis strongly suggests either migraine with autonomic features or cluster headache rather than primary ocular pathology. 4, 5 Notably, 56% of migraine patients report nasal congestion, 37% have eyelid edema, and 22% experience conjunctival injection, which are commonly misattributed to sinus disease. 5

Pain quality and triggers: Ask specifically about throbbing versus pressure quality, and whether weather changes (83% of migraineurs), seasonal variation (73%), allergen exposure (62%), or altitude changes (38%) trigger symptoms. 5, 3

Critical Diagnostic Distinctions

Migraine characteristics: Duration 4-72 hours, pulsating quality, moderate-to-severe intensity, aggravated by routine physical activity, with photophobia, phonophobia, or nausea/vomiting. 4 Importantly, 76% of migraine patients report pain in the maxillary/periorbital distribution (second division of trigeminal nerve), and 62% experience bilateral forehead and maxillary pain, which is frequently misdiagnosed as "sinus headache." 5

Cluster headache features: Severe unilateral supraorbital or temporal pain lasting 15-180 minutes, occurring 1-8 times daily in clusters, with ipsilateral autonomic symptoms and restlessness. 4 This requires neurology referral. 2

Tension-type headache: Bilateral pressing/tightening quality, mild-to-moderate intensity, no aggravation with physical activity, and absence of autonomic features. 1, 4

Physical Examination Priorities

Ophthalmologic Assessment

Key principle: Most ocular causes of pain produce a red eye, alerting to local pathology. 6 However, eyestrain, intermittent angle-closure glaucoma, and low-grade intraocular inflammation can cause pain without obvious redness. 6

Perform focused examination including:

• Visual acuity to screen for vision-threatening conditions 3
• Pupillary examination for relative afferent pupillary defect or anisocoria 3
• External examination for conjunctival injection, eyelid edema, or ptosis 3
• Intraocular pressure if glaucoma suspected (though air travel and cabin pressure do not typically affect glaucoma patients) 3

Neurological Examination

Cranial nerve assessment: Check for diplopia suggesting orbital lesions, isolated cranial neuropathies, or cavernous sinus pathology. 6 Examine for Horner's syndrome (ptosis, miosis, anhidrosis), which may indicate cluster headache, carotid dissection, or parasellar lesions. 6

Motor and sensory examination: Any focal deficits mandate immediate neuroimaging. 1, 2

Diagnostic Algorithm

If No Red Flags Present:

Step 1: Apply diagnostic criteria for primary headache disorders. 1, 4

Step 2: If migraine diagnosed (most likely in this age group with periorbital pressure and headache), initiate acute treatment with naproxen sodium 500-825 mg or combination aspirin + acetaminophen + caffeine. 1 Limit acute treatment to ≤2 days per week to prevent medication overuse headache. 1

Step 3: Screen for medication overuse if non-opioid analgesics used ≥15 days/month for ≥3 months. 1

Step 4: Consider preventive therapy if headaches occur ≥2 times per month causing significant disability. 1

If Diagnosis Uncertain or Atypical Features:

Neuroimaging indication: MRI brain is indicated for unexplained abnormal neurologic examination findings or atypical features that don't fit established primary headache patterns. 1, 2 However, neuroimaging is not recommended if the patient is not at higher risk than the general population and results would not change management. 3

Specialist referral: Refer to neurology if diagnosis remains uncertain after thorough evaluation, poor response to preventive strategies, motor weakness develops, or chronic daily headache pattern emerges. 2

Common Diagnostic Pitfalls

"Sinus headache" misdiagnosis: Studies demonstrate that 68% of patients with self-diagnosed "sinus headache" actually have migraine, 27% have tension-type headache, and only 3-5% have true rhinosinusitis. 7, 5 The presence of nasal congestion, rhinorrhea, and facial pressure does not indicate sinus disease, as these are common autonomic features of migraine. 5, 8

Unnecessary sinus interventions: Avoid empiric antibiotics, sinus endoscopy, or nasal septoplasty without objective evidence of chronic rhinosinusitis on examination or imaging. 7 In one study, 73% of tension-type headache patients and 66% of migraine patients received inappropriate recurrent antibiotic therapy. 7

Primary ocular disease overdiagnosis: While conditions like intermittent angle-closure glaucoma can cause periorbital pain without redness, the vast majority of young patients with eye pressure and headache have primary headache disorders rather than ophthalmologic pathology. 6, 9 Reserve ophthalmology referral for patients with visual acuity changes, abnormal pupillary responses, or persistent symptoms despite appropriate headache treatment. 3