Worst Headache of Life in Neuro-Ophthalmology

Summary: Worst headache of life I. Introduction a. Rarely good-go to hospital immediately b. Neuro-ophthalmology will use CT and combination of diagnostic criteria to make diagnosis II. Differential diagnosis a. Aneurysm i. Rupture of subarachnoid hemorrhage 1. Symptoms and signs include papilledema, photosensitivity, non-localizing cranial nerve (CN) VI palsy ii. Non-ruptured aneurysm--CN III palsy 1. Usually pupil is involved iii. Testing 1. CT angiogram first, then MRI (usually MRA with contrast), then Digital subtraction angiography (DSA) b. Giant cell arteritis i. Consider in an elderly person c. Apoplexy of pituitary gland i. Consider in a young person 1. Visual field test looking for homonymous hemianopsia, or bitemporal hemianopsia 2. Testing a. Non-contrast CT, CTA, MRI/MRA d. Arterial dissection i. Carotid or vertebral dissection 1. Usually pain in neck but can refer to head, face, or eye 2. Carotid dissection is associated with Horner's syndrome 3. Vertebral dissection associated with diplopia from unilateral or bilateral ophthalmoplegia and Horner's syndrome ii. Testing 1. CT, CT angiogram of head and neck, and MRI/MRA of head and neck [Questions] "How do we differentiate the above-mentioned diagnoses from a cluster headache and/or a migraine? These are benign causes of a headache and the vast majority of headaches presenting in the ED (or even in the Eye Casualty) are benign and it's impractical to scan them all? Could you please shed some light regarding differentiating the diagnoses mentioned in your lecture versus a cluster headache and/or a migraine? Thanks." Differentiating between these is critical and can be challenging so the first step is a thorough and careful history. Keeping an eye out for red flags and atypical symptoms such as whether the patient has other systemic symptoms, a secondary diseases like HIV, or neurological symptoms; whether the headache was sudden in onset; whether the patient is elderly; and what the previous headache history is for this patient are essential to determining whether it is a primary or a secondary headache. A good history and physical exam leading to a high clinical suspicion would lead to imaging via a CT or CTA which would identify the presence of an aneurysm or other vascular cause. Cluster headaches usually present in males more than females in their 20s and are associated with ipsilateral lacrimation and conjunctival injection. Patients usually prefer to pace since pain in increased while lying down. Knowing the typical presentations and keeping a broad differential should be helpful in distinguish these disorders from each other.