OP10.3 | Headache and Refractive Error Referral Decisions — Summary & Reflection

KEY TAKEAWAYS

Headache and Refractive Error — Key Points:

• Refractive headache is caused by sustained accommodative effort: mainly hypermetropia (excess accommodation even at distance) and astigmatism (no single focal plane). Myopia does NOT typically cause headache (near vision requires no accommodation in a myope).
• Presbyopia (age 40+, loss of accommodation) causes near headache relieved by reading glasses.
• Clinical pattern: frontal/brow ache, triggered by sustained near work, relieved by rest, worst in afternoon.
• Pinhole test: VA improves → refractive cause. VA does NOT improve → organic cause — refer.
• Acute angle-closure glaucoma must be excluded: sudden headache + red eye + hazy cornea + fixed mid-dilated pupil + haloes = OPHTHALMIC EMERGENCY — not a refractive headache.
• Red flag features (thunderclap, progressive, morning headache, papilloedema, fever + neck stiffness) → urgent neurology/medicine, NOT ophthalmology.
• Convergence insufficiency causes near headache but is not corrected by spectacles — refer to orthoptist.
• Management: correct the refractive error → reassess at 6–8 weeks. Persisting headache despite correct spectacles = refer to ophthalmology.

REFLECT

Think back to the schoolteacher in the hook — she had two visits for the same complaint before the refractive cause was considered. How many consultations were wasted because neither doctor checked her near visual acuity or performed a cycloplegic refraction? Now think about the reverse: how often might a patient with acute angle-closure glaucoma present to a general practitioner with 'headache and vomiting' without the red eye being examined? The lesson is bilateral — both over-attribution (calling all headache 'eye strain') and under-attribution (missing the acute glaucoma) carry harm. A systematic approach to every headache patient — check VA, check the eye, screen for red flags — takes three minutes and prevents both errors.