In this lecture we'll talk about headaches that present with prominent visual disturbance.
Let's start with a case.
This is a 67-year-old woman who has a history of migraines until menopause.
She now presents with two months of new chronic daily headache
as well as tenderness in the scalp and shoulder aching, and a 15-pound weight loss.
Yesterday she has an episode where she was completely unable to see from her right eye,
in other words, transient monocular vision loss.
Her exam is now normal. What type of headache syndrome is this?
Well, there's a number of key features
that we're seeing here that we should associate with this headache syndrome.
This patient has scalp tenderness, myalgias, and weight loss.
This makes us concerned about some underlying inflammatory
or other underlying condition that may also be presenting
with headache would be the root cause of this headache syndrome.
Importantly, this patient presents with headache with vision dysfunction,
and here we have a patient with transient monocular vision loss
which points us to think about this category of headache conditions,
headache with visual dysfunction. Is this a primary or secondary headache syndrome?
Well, headache was a vision dysfunction points us
in the direction of secondary headache syndrome
and this requires urgent management and evaluation.
So what's the optimal management and evaluation for this headache?
Should we, one, get an immediate CT of the head without contrast
or test erythrocyte sedimentation rate
and see how C-reactive protein for giant cell arteritis.
Refer to ophthalmology to evaluate for ocular etiology or perform an MRI of the brain.
Oh, we have visual disturbances, we might think that referral to ophthalmology is the first step,
but that's not the first step for evaluating this patient.
If this patient does in fact have giant cell arteritis, which I would be concerned about,
this requires prompt treatment prior to consideration of temporal artery biopsy,
so the first step is to evaluate the giant cell arteritis.
They are in a clinic or emergency department,
and ophthalmologic involvement may be considered urgently
within the next several weeks.
Should we perform an MRI of the brain?
That may be needed, but again,
not the first step for the evaluation and management of this patient.
Head CT is important for thunderclap headaches.
Patients who have possible subarachnoid hemorrhage,
an imaging may be needed for this patient
but this is not the first and most appropriate step for this patient.
Testing of erythrocyte sedimentation rate and C=reactive protein is the best first step,
and that's the right answer here.
This is indicated for patients greater than 50 years of age
who have a new onset of headache or a change in their typical headache pattern and vision loss.
So that's what we would do for this patient.