What is the recommended management for a patient with new frequent headaches and recent onset of clumsiness characterized by objects slipping from the hands?

Urgent Neuroimaging Required for Suspected Intracranial Pathology

This patient requires immediate brain MRI with and without contrast to evaluate for a space-occupying lesion, stroke, or other structural pathology causing both progressive headaches and new-onset motor dysfunction (dropping objects). The combination of ongoing headaches with new neurological symptoms (clumsiness/dropping objects) represents critical red flags mandating urgent diagnostic workup before any symptomatic treatment 1, 2, 3.

Critical Red Flags Present

This presentation contains multiple concerning features that distinguish it from benign primary headache:

• New neurological deficit (dropping objects/"things slip out of my hands") indicates possible motor pathway involvement, cerebellar dysfunction, or sensory impairment 1, 3, 4
• Progressive or persistent headache pattern rather than episodic attacks suggests secondary cause 1, 5, 3
• The combination of headache with focal neurological symptoms raises concern for stroke, hemorrhage, tumor, or other mass lesion 2, 3, 6

Immediate Diagnostic Workup

Neuroimaging Protocol

Brain MRI with and without contrast is the preferred initial study as it provides superior detection of tumors, ischemia, posterior fossa lesions, and other structural abnormalities compared to CT 2, 5. MRI can identify space-occupying lesions, vascular malformations, inflammatory processes, and demyelinating disease that could explain both symptoms 2.

If MRI is unavailable or contraindicated, non-contrast head CT should be obtained immediately, though it has lower sensitivity for many pathologies 1, 5.

Additional Urgent Evaluation

• Complete neurological examination focusing on motor strength, coordination, sensory function, cerebellar signs, and cranial nerves 3, 6
• Fundoscopic examination to assess for papilledema suggesting increased intracranial pressure 2, 3
• If imaging is normal but clinical suspicion remains high, lumbar puncture may be indicated to evaluate for inflammatory conditions, infection, or CSF pressure abnormalities 1, 2

Laboratory Testing

While neuroimaging takes priority, obtain:

• Thyroid function tests (TSH, free T4) as thyroid disorders can cause both tremor/motor symptoms and headaches 2
• Complete blood count and basic metabolic panel to evaluate for systemic causes 2
• ESR/CRP if temporal arteritis is considered (particularly if patient >50 years old) 7, 8

Management Based on Imaging Results

If Structural Abnormality Identified

• Immediate neurosurgical or neurology consultation for tumors, hemorrhage, or other lesions requiring intervention 1, 2
• Treatment directed at underlying pathology rather than symptomatic headache management 5

If Imaging Normal

Only after excluding secondary causes should primary headache treatment be considered:

• For chronic migraine (≥15 headache days/month for >3 months): Topiramate 50-100 mg daily is first-line prophylaxis 5, 3
• OnabotulinumtoxinA is the only FDA-approved therapy specifically for chronic migraine prophylaxis 1, 5
• Acute treatment with NSAIDs plus triptans for breakthrough headaches 1, 3

Critical Pitfall to Avoid

Do not initiate migraine treatment without first obtaining neuroimaging in patients with red flag features. Treating presumed "migraine" symptomatically while missing a brain tumor, subdural hematoma, or stroke can result in catastrophic outcomes 1, 9, 6. The threshold for neuroimaging must be low when neurological deficits accompany headache 3, 4.

Referral Considerations

• Immediate neurology or neurosurgery referral if imaging reveals structural pathology 2
• Neurology referral for ongoing management if imaging normal but symptoms persist or worsen 3, 8

The motor symptoms ("dropping things") cannot be explained by primary headache disorders and demand investigation for central nervous system pathology before any other intervention 2, 3, 4.