Case: 67-year-old Woman with History of Migraines

00:01 In this lecture we'll talk about headaches that present with prominent visual disturbance.

00:06 Let's start with a case.

00:08 This is a 67-year-old woman who has a history of migraines until menopause.

00:14 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.

00:24 Yesterday she has an episode where she was completely unable to see from her right eye, in other words, transient monocular vision loss.

00:32 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.

00:44 This patient has scalp tenderness, myalgias, and weight loss.

00:47 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.

00:59 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.

01:28 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.

01:43 Refer to ophthalmology to evaluate for ocular etiology or perform an MRI of the brain.

01:49 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.

01:57 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.

02:11 They are in a clinic or emergency department, and ophthalmologic involvement may be considered urgently within the next several weeks.

02:20 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.

02:28 Head CT is important for thunderclap headaches.

02:32 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.

02:42 Testing of erythrocyte sedimentation rate and C=reactive protein is the best first step, and that's the right answer here.

02:49 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.

02:58 So that's what we would do for this patient.