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

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

This presentation requires urgent evaluation to exclude life-threatening causes—specifically subarachnoid hemorrhage, posterior circulation stroke, idiopathic intracranial hypertension, and acute angle-closure glaucoma—before considering benign diagnoses like vestibular migraine or medication effects.

Immediate Red-Flag Assessment

The combination of headache, dizziness, and visual disturbance in a young adult mandates immediate exclusion of subarachnoid hemorrhage if the headache is sudden-onset ("thunderclap"), reaches maximal intensity within seconds, or is described as "worst ever." 1 Even without classic thunderclap features, the triad of symptoms warrants systematic evaluation because 75-80% of posterior circulation strokes present without focal neurologic deficits 2, and young adults can harbor unruptured aneurysms or arterial dissections 2.

Critical History Elements to Obtain Immediately:

• Headache onset and character: Sudden vs gradual, maximal intensity timing, "worst headache ever" description, onset during exertion or Valsalva 1
• Visual symptom specifics: Transient (<1 minute) vs persistent, monocular vs binocular, positional triggers, halos around lights 3, 4
• Dizziness characterization: True vertigo (spinning sensation) vs lightheadedness, duration (seconds/minutes/hours/days), positional triggers 2
• Associated symptoms: Nausea/vomiting (multiple episodes suggest serious pathology 2), neck pain, photophobia, phonophobia 5
• Vascular risk factors: Oral contraceptive use (increases cerebral venous thrombosis risk 2), smoking, family history of aneurysm 1
• Trauma history: Even minor head/neck trauma within past weeks 3, 2

Algorithmic Diagnostic Approach

Step 1: Rule Out Subarachnoid Hemorrhage and Stroke

If headache is thunderclap-onset OR accompanied by multiple vomiting episodes OR patient appears acutely ill:

• Obtain non-contrast CT head immediately 1
• If CT negative but clinical suspicion remains, proceed immediately to CTA head to evaluate for aneurysms (identifies vascular abnormalities in 7.4% of cases with normal CT) 1
• Do NOT assume normal CT excludes SAH—up to 5.4% have aneurysms requiring identification 1

If dizziness is prominent with acute onset (hours to days) and patient has vascular risk factors (age considerations, oral contraceptives, smoking):

• MRI brain without contrast with diffusion-weighted imaging is first-line (4% diagnostic yield vs <1% for CT) 2
• CT head misses most posterior circulation infarcts (sensitivity only 10-20%) and should not substitute for MRI 2
• Even with normal neurologic exam, obtain MRI if patient is on oral contraceptives or has other prothrombotic risk 2

Step 2: Assess for Idiopathic Intracranial Hypertension (IIH)

IIH is the leading diagnosis in young women with this symptom triad, particularly if obesity is present. 3

Diagnostic criteria require:

• Papilledema on fundoscopic exam (perform dilated exam if safe) 3
• Normal neurologic exam except for cranial nerve abnormalities 3
• Normal brain imaging (MRI/MRV to exclude venous sinus thrombosis) 3
• Elevated opening pressure on lumbar puncture (>25 cm H₂O) with normal CSF composition 3

Key clinical features pointing to IIH:

• Transient visual obscurations (seconds of bilateral vision darkening, often positional) 3
• Pulsatile tinnitus 3
• Headache that is progressively worsening in frequency and severity 3
• Horizontal diplopia (from sixth nerve palsy) 3

Critical pitfall: Papilledema may be absent in early IIH or "IIH without papilledema" variant—if clinical suspicion is high, proceed with neuroimaging and LP regardless 3.

Step 3: Evaluate for Acute Angle-Closure Glaucoma

If blurred vision is accompanied by:

• Eye pain or foreign body sensation 4
• Halos around lights 4
• Mid-dilated or poorly reactive pupil 4
• Severe headache with nausea 4

This constitutes an ophthalmologic emergency requiring immediate IOP measurement and urgent ophthalmology referral to prevent permanent vision loss 4.

Step 4: Characterize Dizziness to Guide Further Workup

The timing and triggers of dizziness are more diagnostically valuable than the patient's subjective description 2.

Brief episodic vertigo (seconds to <1 minute, triggered by head position changes):

• Perform Dix-Hallpike maneuver bilaterally 2
• If positive (latency 5-20 seconds, torsional upbeating nystagmus, resolution <60 seconds), diagnose BPPV 2
• No imaging needed for typical BPPV with positive Dix-Hallpike and no red flags 2
• Treat immediately with Epley maneuver (80% success after 1-3 treatments) 2

Acute persistent vertigo (hours to days, constant symptoms):

• Perform HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if trained 2
• CAUTION: HINTS is unreliable when performed by non-experts—do not rely on it alone in emergency settings 2
• If high vascular risk OR abnormal HINTS, obtain MRI brain without contrast immediately 2

Spontaneous episodic vertigo (minutes to hours):

• Consider vestibular migraine (14% of all vertigo cases, markedly under-recognized in young adults) 2
• Diagnostic criteria: Episodic vestibular symptoms + migraine by International Headache Society criteria + ≥2 migraine features during ≥2 vertiginous episodes 2
• Associated features: Headache, photophobia, phonophobia, motion intolerance 2, 5

Step 5: Consider Medication-Induced Causes

Medication side effects are the most common reversible cause of chronic dizziness 2.

Systematically review:

• Antihypertensives 2
• Oral contraceptives (also increase stroke/thrombosis risk) 2
• Sedatives, anticonvulsants, psychotropic drugs 2

Physical Examination Priorities

Perform immediately:

• Vital signs including orthostatic measurements (standing BP/HR after 3 minutes supine) 2
• Fingerstick glucose (hypoglycemia is most common unexpected lab abnormality) 2
• Dilated fundoscopic exam to assess for papilledema (if no contraindications) 3
• Pupil assessment for mid-dilation, asymmetry, or poor reactivity 4
• Visual acuity and confrontational visual fields 3
• Dix-Hallpike maneuver bilaterally 2
• Neurologic exam focusing on focal deficits, dysarthria, limb weakness, sensory loss 2

When Imaging IS Indicated

Obtain MRI brain without contrast (NOT CT) for:

• Thunderclap headache with negative initial CT 1
• Vascular risk factors (oral contraceptives, smoking, family history) with acute vestibular syndrome 2
• Abnormal neurologic examination 2
• New severe headache accompanying dizziness 2
• Focal neurologic deficits 2
• Inability to stand or walk 2
• Downbeating or direction-changing nystagmus 2
• Unilateral or pulsatile tinnitus 2
• Progressive neurologic symptoms 2

Add MRV (venography) if:

• Suspicion for IIH or cerebral venous sinus thrombosis 3
• Patient on oral contraceptives with headache 2

When Imaging Is NOT Indicated

• Typical BPPV with positive Dix-Hallpike, no red flags, normal neurologic exam 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 2
• Confirmed vestibular migraine meeting diagnostic criteria without atypical features 2

Management Based on Diagnosis

If SAH or stroke identified:

• Immediate neurosurgery/neurology consultation and transfer to appropriate level of care 1

If IIH confirmed:

• Acetazolamide for medical management 3
• Weight loss counseling 3
• Serial visual field testing to monitor for vision loss 3
• Neurosurgery referral if vision-threatening 3

If BPPV confirmed:

• Epley maneuver immediately (90-98% success with repeat maneuvers) 2
• Reassess within one month 2
• Counsel on recurrence risk and fall prevention 2
• Avoid vestibular suppressants (meclizine, benzodiazepines)—they delay compensation 2

If vestibular migraine diagnosed:

• Migraine prophylaxis and lifestyle modifications 2
• Acute treatment with NSAID-triptan combination (naproxen 500-550mg + sumatriptan 50-100mg) if not pregnant/breastfeeding 2
• Educate about medication-overuse headache risk (NSAIDs ≥15 days/month, triptans ≥10 days/month) 2

If medication-induced:

• Medication adjustment or discontinuation 2
• Consider alternative contraception if oral contraceptives implicated 2

Critical Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes lack focal deficits 2
• Relying on CT instead of MRI for suspected stroke—CT misses most posterior circulation infarcts 2
• Assuming "just another migraine" without excluding dangerous causes first 1
• Failing to check for papilledema in young women with headache 3
• Ordering routine comprehensive lab panels—they rarely change management; focus on glucose only 2
• Prescribing vestibular suppressants for BPPV—they don't correct the mechanical problem 2
• Missing medication review as reversible cause 2