Headache and the Eye

Ula Jurkunas, MD; John W. Gittinger, JR, MD

Disclosures

Compr Ophthalmol Update. 2004;5(4) 

In This Article

Headache Due to Intracranial and Blood Pressure Changes

Bilateral disk edema in a patient with headache most often represents papilledema and warrants urgent neuroimaging to rule out tumor, hydrocephalus, or bleeding. The headache of increased intracranial pressure need not be severe, but it is often present on awakening and associated with vomiting. When neuroimaging is normal, the next step is referral for lumbar puncture to measure intracranial pressure and determine cerebrospinal fluid (CSF) composition. The diagnosis of pseudotumor cerebri, or idiopathic intracranial hypertension, is established by normal neuroimaging and CSF composition with elevated intracranial pressure. The ophthalmologist should not consider this entity benign, as chronic papilledema may lead to blindness. Treatment includes weight reduction, diuretics (especially acetazolamide), shunting, and optic nerve sheath fenestration.

Low intracranial pressure also may cause headache and is encountered after lumber puncture or with spontaneous CSF leaks.[74] Imaging may show thickened meninges on T1 that enhance with gadolinium.

Headache from elevated blood pressure may be accompanied by bilateral disk swelling, a variant of malignant hypertension, in which medical treatment may preserve life and vision.

We all learned in medical school that a patient reporting the worst headache of his or her life may have subarachnoid hemorrhage.

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