Why recurrent headache with visual symptoms matters
Headache is one of the commonest complaints in any clinic, and almost all of it is primary headache. The job is to make a confident diagnosis from the history, and to know the handful of features that mean this headache is different and needs more.
What to ask in the history
- The visual symptoms: what she sees, how they spread, how long they last, whether they are in one eye or both
- Other symptoms before the headache: tingling, numbness, weakness, difficulty speaking
- The headache: site, character, how quickly it peaks, how long it lasts
- Nausea, vomiting, sensitivity to light and sound
- How often, and what triggers it: sleep, stress, food, periods
- How many days a month she takes painkillers
- Contraceptive pill use
- Family history of similar headaches
Red flags
- A sudden, thunderclap headache, or the worst headache of her life
- Fever, neck stiffness or a rash
- Weakness, numbness or visual loss that does not go away
- Aura lasting more than an hour, or aura without a headache for the first time
- Headache worse lying down or on coughing, or with papilloedema
- A new headache in pregnancy or in someone with cancer or low immunity
What to examine
- Full neurological examination, including visual fields and eye movements
- Fundoscopy for papilloedema
- Blood pressure
- Neck stiffness, temporal tenderness
First investigations
- Often none, if the history is typical and the examination is normal
- Imaging (CT or MRI) only if there are red flags
- A headache diary to record frequency, triggers and painkiller use
Differential diagnosis of recurrent headache with visual symptoms
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Primary headache
- Migraine with or without aura
- Tension-type headache
- Cluster headache
- Medication overuse headache
Secondary, must not miss
- Subarachnoid haemorrhage
- Cerebral venous sinus thrombosis
- Idiopathic intracranial hypertension
- Meningitis
Mimics of the visual symptoms
- Transient ischaemic attack
- Occipital lobe seizure
- Retinal detachment (flashes in one eye)
Common mistakes
- Imaging everyone. A typical history with a normal examination rarely needs a scan.
- Not asking about the contraceptive pill. It matters for which treatments are safe.
- Missing medication overuse, which keeps headaches going.