What is the most likely diagnosis and recommended management for a 28-year-old man with intermittent dull occipital headache lasting about 30 minutes, worsened by prolonged computer use and sleep deprivation, accompanied by blurred vision that improves when screen exposure stops, with a normal neurologic examination and normotensive vital signs?

Most Likely Diagnosis: Computer Vision Syndrome with Tension-Type Headache

This 28-year-old man most likely has computer vision syndrome (CVS) with secondary tension-type headache, triggered by prolonged screen exposure and compounded by sleep deprivation. 1, 2

Clinical Reasoning

Key Diagnostic Features Supporting CVS with Tension-Type Headache

• Occipital location with dull, heavy quality matches the typical presentation of tension-type headache, which presents as bilateral pressing/tightening pain of mild-to-moderate intensity 2, 3

• Direct aggravation by computer use is the hallmark of CVS, which affects 75-90% of computer users and is triggered by extended screen time (>4 hours daily) 1

• Blurred vision relieved by removing screen exposure is a cardinal symptom of CVS, specifically indicating ocular-motor dysfunction with accommodation anomalies and asthenopia (eye strain) 1

• Sleep deprivation as an aggravating factor is well-established, as insufficient sleep (1-3 hours loss) causes headaches described as "dull ache, heaviness or pressure sensation felt in the forehead and/or vertex" lasting hours to all day 4

• Relief with simple analgesics and sleep is characteristic of both tension-type headache and sleep deprivation headache, with complete or marked pain reduction in 20-60 minutes 2, 4

Critical Exclusions

• Migraine is ruled out because the patient lacks: unilateral pulsating quality, moderate-to-severe intensity preventing routine activity, nausea/vomiting, and photophobia with phonophobia 2. The blurred vision is not a true migraine aura (which would involve scintillations, zigzag lines, and last 5-60 minutes with gradual spread) 1, 2

• Cervicogenic headache is excluded because pain is aggravated by computer use and posture rather than cervical movement, and there is no mention of reduced cervical range of motion or myofascial tenderness 1

• Occipital neuralgia is ruled out because the pain is dull and continuous rather than paroxysmal lancinating/stabbing pain in brief episodes, and there is no hypersensitivity to touch in the occipital nerve distribution 5, 6, 7

• Spontaneous intracranial hypotension is excluded because the headache is not truly orthostatic (it doesn't meet criteria of being absent/mild on waking, onset within 2 hours of upright posture, and >50% improvement within 2 hours of lying flat) 1

• Red flags are absent: no thunderclap onset, no progressive worsening over weeks, no focal neurological deficits, no fever/neck stiffness, no age >50 years, and normal neurological examination 2

Immediate Management Steps

1. Confirm Diagnosis with Targeted Assessment

• Administer CVS screening questionnaire (Segui et al. 16-item questionnaire; score ≥6 is diagnostic of CVS) to quantify frequency and intensity of computer-related eye strain symptoms 1

• Assess accommodation and convergence function through near point of convergence testing, accommodation amplitude, and reading assessment to identify ocular-motor dysfunction 1

• Document sleep patterns with a headache diary recording hours of sleep, screen time duration, headache onset/offset, and medication use to establish temporal relationships 2

2. Environmental and Ergonomic Modifications (First-Line)

• Implement the 20-20-20 rule: Every 20 minutes, look at something 20 feet away for 20 seconds to reduce accommodation strain 1

• Optimize workstation ergonomics: Position screen 20-26 inches from eyes, top of screen at or slightly below eye level, reduce glare and reflections from surrounding lighting, and maintain room humidity >40% 1

• Enforce sleep hygiene: Target 7-8 hours of sleep nightly, as sleep restoration is critical for brain function and headache prevention 4, 8

3. Pharmacological Management

• Continue paracetamol 500-1000 mg as needed for acute headache episodes (effective within 20-60 minutes for tension-type and sleep deprivation headaches) 2, 4

• Consider NSAIDs (ibuprofen 400-600 mg) as an alternative if paracetamol becomes less effective 2

• Avoid medication overuse: Monitor that acute medication use stays below 15 days/month for simple analgesics to prevent medication-overuse headache 2

4. Ophthalmologic Evaluation

• Refer to optometry/ophthalmology for comprehensive eye examination including refraction, binocular vision assessment, and evaluation for uncorrected refractive error or convergence insufficiency 1

• Consider artificial tears if dry eye symptoms develop (common with reduced blink rate during screen use) 1

5. When to Escalate Care

• No neuroimaging is indicated at this time given the normal neurological examination, absence of red flags, and clear temporal relationship to modifiable triggers (screen time and sleep deprivation) 2

• Refer to neurology if: Headaches persist despite 4-6 weeks of environmental modifications and adequate sleep, pattern changes to progressive worsening, or new neurological symptoms develop 2

Common Pitfalls to Avoid

• Do not misdiagnose as migraine based solely on visual symptoms—CVS causes blurred vision from accommodation dysfunction, not true migraine aura with scintillations 1, 2

• Do not overlook sleep deprivation as a primary contributor—6 hours of sleep with recent lodging changes is insufficient and directly causes headaches independent of screen use 4, 8

• Do not order unnecessary neuroimaging in patients with normal neurological examination and clear environmental triggers, as the yield is extremely low (0.2%) and no higher than asymptomatic volunteers 2

• Do not prescribe preventive migraine medications (such as topiramate or propranolol) when the diagnosis is tension-type headache with CVS, as addressing the underlying triggers is more appropriate 2