A review of the primary causes of headaches, which have a neuro-ophthalmic significance and are vision-threatening. Med Students are expected to recognize and refer these cases appropriately after completing this presentataion.
Headache: Neuroophthalmic Aspects for Med Students
Raed Behbehani , MD FRCSC
•Periocular pain due to diseases of the face, orbit, sinuses , andintracranial cavity.•Trigeminal innervation (V1-V3).
•Any headache can cause eye pain (and vice versa).•Take good history ( loss of vision, diplopia, transient visualobscurrations, redness, photophobia, jaw claudication, systemicsymptoms).• Examination : check vision at least grossly, look forredness, ptosis, corneal edema, check pupil reactions, palpate the eyesand orbits, check sensation v1-v3 and other cranial nerves.•FUNDOSCOPY !
Stat ESR , CRP and CBC (platelets).ESR can be normal in 15-20% of cases.CRP is more sensitive and specific.CRP and CBC have 97% sensitivity and specifity.Start high dose systemic steroids (IV or Oral ) immediately uponsuspicioun !Arrange for temporal artery biopsy within 2 weeks , while patient ison steroids.
• Treatment is long term high dose systemic steroids (1-2 years)• Rheumatological consultation to rule out systemic involvement (aortic aneurysm or dissection)• Follow up clinically and with CRP and ESR to titrate steroid dose• Protention against steroid complications ( diabetes, osteoporosis)
• Optic neuritis.• Orbital inflammtory disease.
• Dull , aching pain worse with eye movements.• Loss of vision.• Pupil testing : relative afferent pupillary defect (RAPD).• Loss of color vision (Dyschromatopsia).• Fundus : optic disc normal in 70% (retrobulbar optic neuritis).
• Sudden onset.• Pain, proptosis, limited eye movement, chemosis.• Idiopathic or due to Wegener’s granulmatosis, Grave s’ disease,sarcoidosis)
• Headache, pain in the neck and shoulders and upper back.• Worse with coughing/straining.• Pulsatile tinnitis.•Transient visual obscurations.• Diplopia ( Abducens nerve palsy )
1) Symptoms of raised intracranial pressure (headache, nausea, vomiting, transient visual obscurations, or papilledema)2) No localizing signs with the exception of abducens (sixth) nerve palsy3) The patient is awake and alert4) Normal CT/MRI findings without evidence of thrombosis5) LP opening pressure of >25 cmH2O and normal biochemical and cytological composition of CSF 6 No other explanation for the raised intracranial pressure
• Take good history ( try to distinguish primary from secondaryheadache syndrome).• Look for abnormal neuro-ophthalmic signs (Ptosis, ophthalmoplegia, abnormal facial sensation, check visualacuity, and pupils, and look for papilledema).• Giant cell arteritis is vision-threatening.•Papilledemaican be life threatening.