What is the appropriate evaluation and management for a 27‑year‑old adult presenting with new onset headache, dizziness, and blurred vision?

Evaluation and Management of a 27-Year-Old with Headache, Dizziness, and Blurred Vision

Immediate Priority: Rule Out Life-Threatening Secondary Causes

This presentation requires urgent neuroimaging with non-contrast head CT to exclude subarachnoid hemorrhage, intracranial mass, or cerebral venous thrombosis before considering any primary headache disorder. 1, 2, 3

The combination of headache, dizziness, and blurred vision represents red flag symptoms that mandate immediate evaluation for secondary causes, particularly given the progressive nature and multiple neurologic symptoms. 1, 3

---

Critical Red Flags Present in This Case

• Multiple neurologic symptoms (headache + dizziness + vision changes) indicate possible increased intracranial pressure, posterior circulation pathology, or meningeal irritation 1, 3
• Vision changes (blurred vision) can indicate papilledema from elevated intracranial pressure, cerebral venous thrombosis, or vascular pathology 4, 1
• Dizziness combined with headache and visual symptoms raises concern for posterior circulation stroke, intracranial hypotension, or vestibular pathology 5, 6

---

Immediate Diagnostic Algorithm

Step 1: Emergency Department Evaluation

• Obtain emergent non-contrast head CT as the first imaging study to exclude acute intracranial hemorrhage, mass effect, or hydrocephalus with 98% sensitivity for subarachnoid hemorrhage within 6 hours 1, 3
• Measure blood pressure immediately to exclude malignant hypertension as a cause of headache and visual symptoms 4, 2
• Perform complete neurologic examination including mental status, cranial nerves (especially VI nerve function given diplopia risk), motor/sensory function, fundoscopic examination for papilledema, and cerebellar testing 4, 2, 3

Step 2: If CT Shows No Hemorrhage

• Proceed immediately to lumbar puncture if CT is negative but clinical suspicion for subarachnoid hemorrhage remains high, performing LP >6 hours from symptom onset to allow xanthochromia development 1
• Measure opening pressure in lateral decubitus position (normal <200 mm H₂O) and analyze CSF for cell count, xanthochromia, Gram stain, and culture 4, 1
• Order MRI brain with and without contrast if CT is negative and LP is not immediately indicated, as MRI provides superior detection of venous thrombosis, posterior circulation stroke, leptomeningeal disease, and small masses 2, 3

Step 3: Additional Imaging Based on Initial Findings

• CT or MR venography is mandatory within 24 hours to exclude cerebral venous sinus thrombosis, which can present with headache, visual symptoms, and dizziness 4, 1
• MRI brain and orbits with contrast if papilledema is found on fundoscopy, looking for empty sella, posterior globe flattening, optic nerve sheath enlargement, and horizontal tortuosity of optic nerve 4

---

Key Physical Examination Findings to Document

• Fundoscopic examination: Check specifically for papilledema (disc elevation, blurred margins, absent venous pulsations) versus normal optic disc 4, 3
• Pupillary examination: Assess for relative afferent pupillary defect, anisocoria, or poor reactivity 5, 4
• Extraocular movements: Test for sixth nerve palsy (inability to abduct eye), which can occur with elevated intracranial pressure or posterior circulation pathology 5, 4
• Neck examination: Assess for nuchal rigidity or pain with flexion, which suggests meningeal irritation from subarachnoid hemorrhage or meningitis 5, 1
• Vestibular testing: Perform head impulse test and Dix-Hallpike maneuver if peripheral vestibular pathology is suspected 6

---

Differential Diagnosis Priority (Most to Least Urgent)

Life-Threatening Causes (Rule Out First)

1. Subarachnoid hemorrhage: Sudden severe headache with neck pain, vision changes, and altered consciousness 1, 3
2. Cerebral venous thrombosis: Progressive headache with vision changes and possible seizures 5, 1
3. Bacterial meningitis: Headache with neck stiffness, fever (though fever may be absent), and altered mental status 5, 1
4. Intracranial mass or hemorrhage: Progressive headache with focal neurologic deficits 1, 2, 3
5. Idiopathic intracranial hypertension: Headache with transient visual obscurations, papilledema, and possible sixth nerve palsy 5, 4
6. Spontaneous intracranial hypotension: Orthostatic headache (worse upright, better lying down) with dizziness and visual symptoms 5

Primary Headache Disorders (Consider Only After Imaging)

1. Migraine with aura: Recurrent headaches with visual aura, photophobia, and family history, but this is a diagnosis of exclusion in new-onset cases 5, 3, 7
2. Vestibular migraine: Episodic dizziness with headache, history of motion sickness, and family history of migraine 6, 8
3. Hemiplegic migraine: Migraine with motor weakness, but requires family history and recurrent episodes for diagnosis 7, 9

---

Management Algorithm After Imaging

If Imaging Reveals Secondary Cause

• Treat underlying pathology immediately - this takes absolute priority over symptomatic headache management 2
• Subarachnoid hemorrhage: Neurosurgical consultation, blood pressure control, nimodipine for vasospasm prevention 1
• Cerebral venous thrombosis: Anticoagulation with heparin even if hemorrhage present (per AHA/ASA guidelines), neurosurgical consultation if deterioration 5, 1
• Bacterial meningitis: Immediate empiric antibiotics (ceftriaxone + vancomycin) before LP if LP delayed, dexamethasone if indicated 5, 1
• Idiopathic intracranial hypertension: Acetazolamide 500-1000 mg twice daily, weight loss counseling, ophthalmology referral for visual field monitoring 5, 4
• Intracranial hypotension: Epidural blood patch if conservative management (hydration, caffeine, bed rest) fails after 1-2 weeks 5

If Imaging Normal and Secondary Causes Excluded

• Acute symptomatic treatment: NSAIDs (ibuprofen 400-800 mg or naproxen 500-550 mg) plus antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg) for moderate symptoms 5
• Triptans: Consider sumatriptan 50-100 mg orally or 6 mg subcutaneously if NSAIDs fail after three consecutive attacks, but only after confirming no cardiovascular contraindications 5
• Vestibular rehabilitation: If dizziness persists and vestibular dysfunction confirmed, refer for vestibular physical therapy 5, 6
• Preventive therapy: Initiate if headaches occur ≥2 days per month despite optimized acute treatment - first-line options include propranolol 80-240 mg daily, topiramate 50-200 mg daily, or candesartan 16 mg daily 5

---

Critical Pitfalls to Avoid

• Never assume migraine without neuroimaging in a patient with new-onset headache and multiple neurologic symptoms - secondary causes must be excluded first 1, 2, 3
• Do not delay CT for lumbar puncture - imaging must be obtained first to rule out mass effect or hemorrhage before LP 1, 3
• Do not miss papilledema - perform careful fundoscopy in all patients with headache and visual symptoms, as papilledema indicates elevated intracranial pressure requiring urgent intervention 4, 3
• Do not overlook cerebral venous thrombosis - this diagnosis requires high clinical suspicion and dedicated venography, as it can present with normal initial CT 5, 1
• Avoid medication overuse - limit acute headache medications to <10 days per month for triptans and <15 days per month for NSAIDs to prevent medication-overuse headache 5

---

Follow-Up Strategy

• Immediate neurology referral if any abnormality found on imaging or if symptoms progress despite normal initial workup 2, 3
• Ophthalmology referral within 24-48 hours if papilledema identified, for formal visual field testing and optical coherence tomography 4
• Re-evaluate in 2-4 weeks if symptoms persist despite normal workup and initial treatment, considering repeat neuroimaging if clinical deterioration 2, 3
• Headache diary to track frequency, severity, triggers, associated symptoms, and medication use for 4-6 weeks 5, 2