What is the workup and management for a patient presenting with diplopia (double vision) and headache?

From the Guidelines

Double vision (diplopia) with headache requires prompt evaluation as it may indicate serious neurological conditions, and urgent neuroimaging with MRI brain with contrast is recommended to rule out intracranial pathology such as tumor, aneurysm, or stroke, as suggested by the most recent study 1.

Key Considerations

• Begin with a thorough history and physical examination, focusing on onset, duration, and pattern of diplopia (monocular vs. binocular), associated symptoms, and neurological signs.
• Laboratory tests should include complete blood count, metabolic panel, inflammatory markers (ESR, CRP), and thyroid function tests.
• If giant cell arteritis is suspected in patients over 50 with new headache, obtain ESR/CRP immediately and start prednisone 60mg daily without delay, as recommended by 1.

Management of Diplopia

• For migraine-associated diplopia, treat with NSAIDs (ibuprofen 400-600mg) or triptans (sumatriptan 50-100mg) for acute episodes, and consider preventive therapy with propranolol (40-160mg daily), topiramate (25-100mg twice daily), or amitriptyline (10-75mg nightly) for frequent episodes.
• For diplopia due to cranial nerve palsies, management depends on the underlying cause, and temporary relief can be provided with an eye patch or prism glasses, as suggested by 1.
• Patients should be advised to avoid driving while experiencing double vision, and urgent referral to neurology and ophthalmology is essential, with emergency evaluation if symptoms are accompanied by altered mental status, severe pain, or other focal neurological deficits.

Additional Considerations

• The connection between diplopia and headache often involves compression or inflammation of cranial nerves controlling eye movement, vascular disorders affecting brain perfusion, or increased intracranial pressure disrupting normal ocular alignment, as discussed in 1.
• A detailed sensorimotor evaluation, assessment of refractive status, and dilated fundus examination should be performed to assess the oculomotor status, including possible ocular torsion impacting fusion, as recommended by 1.
• Monitor and describe whether the letter itself is single or double, and if maintaining a single frame causes diplopia of the letter, peripheral fusion has taken over and foveal diplopia syndrome is present, as suggested by 1.
• Fogging the vision in one eye, which eliminates the foveal conflict by producing a central scotoma, has been the most successful treatment for binocular retinal diplopia, as discussed in 1.

From the Research

Double Vision with Headache Workup and Management

• Double vision, also known as diplopia, is a common concern in neurologic practice, and its sudden onset can cause great apprehension and potential disability for patients 2.
• The experience of diplopia is always sudden and is frequently a cause of great apprehension and potential disability for patients 2.
• Binocular diplopia is most often due to a neurologic cause, and its onset is debilitating for most patients, commonly prompting immediate access to health care services 2, 3.

Diagnosis and Management

• All patients with diplopia of acute onset should be investigated urgently, and those with a headache or pupillary involvement need to be referred for same-day urgent imaging 3.
• A logical, localization-driven, and evidence-based approach is the most effective way to arrive at the correct diagnosis and provide the best outcome for the patient 2.
• Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder 4.
• Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine, while preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA 4.

Neuro-Ophthalmic Symptoms

• Primary headache disorders can cause many ophthalmic symptoms, including photophobia, eye pain, dry eye, autonomic features, and anisocoria, leading patients to present for neuro-ophthalmic evaluation 5.
• Patients with migraine experience a wide range of visual disturbances, including aura and more complex perceptual abnormalities such as Alice in Wonderland syndrome and visual snow 5.
• Diplopia may be caused by pathology in the eye, orbit, extraocular muscles, neuromuscular junction, or in the central nervous system, and its differential diagnosis should consider both common and rare etiologies 6.