In a 27-year-old adult presenting with new-onset headache, dizziness, blurred vision and a pain intensity of 7/10, what is the immediate management?

Immediate Management of Severe New-Onset Headache with Dizziness and Blurred Vision

This 27-year-old requires urgent evaluation to exclude life-threatening secondary causes before treating as primary headache, specifically ruling out subarachnoid hemorrhage, intracranial hypertension, cerebral venous thrombosis, and acute glaucoma. 1, 2

Red Flag Assessment and Immediate Triage

The combination of severe headache (7/10), dizziness, and blurred vision constitutes a red flag presentation requiring emergent evaluation. 1, 3

Critical Red Flags Present in This Case:

• New-onset headache in a young adult with associated neurologic symptoms (dizziness, visual disturbance) mandates exclusion of secondary causes 1, 3
• Blurred vision raises concern for increased intracranial pressure, acute glaucoma, or posterior circulation pathology 4, 1
• Dizziness combined with headache may indicate cerebral venous thrombosis, posterior circulation stroke, or intracranial hypotension 4, 5

Immediate Physical Examination Priorities:

• Vital signs including blood pressure (uncontrolled hypertension contraindicates triptans and NSAIDs) 4, 6
• Fundoscopic examination to detect papilledema suggesting increased intracranial pressure 1, 3
• Focal neurologic deficits including motor weakness, sensory changes, or cranial nerve abnormalities 1, 3
• Meningeal signs (neck stiffness, Kernig's sign, Brudzinski's sign) to exclude meningitis or subarachnoid hemorrhage 1, 2
• Visual acuity and pupillary examination to rule out acute angle-closure glaucoma 1

Emergent Neuroimaging Indications

Non-contrast CT head is the immediate imaging modality of choice to exclude acute intracranial hemorrhage or mass effect. 1, 2

When CT Head is Mandatory:

• Any new-onset severe headache with neurologic symptoms (dizziness, blurred vision) requires CT to exclude subarachnoid hemorrhage, intracerebral hemorrhage, or mass lesion 1, 2
• If CT is performed within 6 hours of headache onset and interpreted by a neuroradiologist, sensitivity for subarachnoid hemorrhage is 98.7% (95% CI 96.5-100%) 2
• If CT is negative and clinical suspicion remains high, lumbar puncture with spectrophotometric analysis is required (sensitivity 100% for subarachnoid hemorrhage) 2

When MRI Brain is Preferred:

• For less urgent evaluation when CT is normal but symptoms persist, MRI brain is superior for detecting cerebral venous thrombosis, posterior circulation infarction, or intracranial hypotension 4, 1
• Cerebral venous thrombosis can present with headache, dizziness, and blurred vision; MRI with venography is diagnostic 4

Acute Treatment Algorithm (After Excluding Secondary Causes)

If Neurologic Examination and Imaging Are Normal:

First-line acute treatment is combination therapy with an NSAID plus an antiemetic, reserving triptans for moderate-to-severe migraine after initial assessment. 4, 7

Step 1: Initial Parenteral Therapy for Severe Headache (7/10)

• Ketorolac 30 mg IV (or 60 mg IM if <65 years old) provides rapid onset with approximately 6 hours duration and minimal rebound headache risk 4, 7
• Metoclopramide 10 mg IV provides direct analgesic effects through central dopamine receptor antagonism plus antiemetic benefit 4, 7
• Prochlorperazine 10 mg IV is an alternative to metoclopramide with comparable efficacy for headache pain 4, 7

Step 2: If Parenteral Therapy Fails or Oral Treatment is Appropriate

• Sumatriptan 50-100 mg PO plus naproxen 500 mg PO is the strongest-rated combination for moderate-to-severe migraine, superior to either agent alone (NNT 3.5 for headache relief at 2 hours) 7, 6
• Contraindications to triptans include uncontrolled hypertension, ischemic heart disease, cerebrovascular disease, basilar or hemiplegic migraine 6

Step 3: Alternative if Triptans are Contraindicated

• Dihydroergotamine (DHE) 0.5-1.0 mg IV has good evidence for efficacy as monotherapy, can be repeated hourly up to 2 mg/day 7
• DHE contraindications include concurrent triptan use within 24 hours, beta-blockers, uncontrolled hypertension, coronary artery disease, pregnancy 7

Critical Medication Frequency Limits:

Limit all acute migraine medications to no more than 2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 4, 7

Medications to Absolutely Avoid

• Opioids (hydromorphone, oxycodone, codeine) should not be used as first-line therapy; they are no more effective than NSAIDs, carry substantial risk of dependence, and cause medication-overuse headache 7
• Butalbital-containing compounds have questionable efficacy and high risk of medication-overuse headache 7

Disposition and Follow-Up

Admit or Observe If:

• Persistent symptoms despite treatment or inability to exclude secondary causes 1, 3
• Abnormal neurologic examination or concerning imaging findings 1, 3
• Suspected cerebral venous thrombosis requires anticoagulation and neurology consultation 4

Discharge with Close Follow-Up If:

• Normal neurologic examination and imaging with symptom improvement after acute treatment 1, 3
• Headache diary to track frequency, triggers, and medication use 4, 8
• Return precautions for worsening headache ("worst headache of life"), fever, neck stiffness, seizure, loss of consciousness, or focal neurologic deficits 1, 3
• Follow-up within 48-72 hours to reassess and consider preventive therapy if headaches recur more than twice weekly 7

Common Pitfalls to Avoid

• Do not treat as primary headache without excluding secondary causes in a patient with new-onset severe headache plus neurologic symptoms 1, 3
• Do not delay imaging when red flags are present; CT within 6 hours has 98.7% sensitivity for subarachnoid hemorrhage 2
• Do not prescribe opioids for acute headache; they worsen long-term outcomes and increase risk of medication-overuse headache 7
• Do not allow frequent acute medication use (>2 days/week); this creates a cycle of medication-overuse headache requiring preventive therapy 4, 7