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The appropriate clinical management and investigation for this patient with strabismus or migraine depends on precise diagnosis, underlying etiology, and patient-specific factors.

Initial assessment should include a comprehensive ocular examination to characterize the type of ocular deviation, ocular motility patterns, binocular vision status, refractive errors, and any associated neurological or systemic conditions. Objective evaluation across multiple gaze positions using technologies such as video-oculography or eye tracking can enhance diagnostic accuracy and functional assessment beyond traditional primary gaze measurements Cantó-Cerdán and Cacho-Martínez P. 2026,NICE CKS.

For patients presenting with acquired or complex strabismus, particularly adults with diplopia, investigations should exclude neurologic causes like cranial nerve palsies, mechanical factors such as extraocular muscle injury, or systemic neurodevelopmental disorders affecting visual pathways. Early recognition of mechanical complications, for instance post-sinus surgery, mandates prompt surgical repair to optimize outcomes Cantó-Cerdán and Cacho-Martínez P. 2026,NICE CKS.

Management integrates both surgical and non-surgical strategies tailored to the individual’s etiology and functional impairments. Surgical approaches may require multi-muscle interventions for paralytic or incomitant strabismus, with postoperative alignment assessed in multiple gaze positions to predict functional success Cantó-Cerdán and Cacho-Martínez P. 2026,NICE CKS. Prism correction combined with targeted surgery may improve diplopia especially in subtypes like distance-predominant adult esotropia Cantó-Cerdán 2026.

Complementary non-surgical rehabilitation, including emerging virtual reality-based perceptual training, shows promise in restoring binocular function and stereopsis even in severe cases, supporting a move from purely motor-centric to sensory and functional outcome-driven care Cantó-Cerdán 2026.

For patients presenting with migraine, especially women, clinical management necessitates a multidisciplinary approach with neurologists/headache specialists as central coordinators collaborating with gynecologists, pediatricians, and oncologists depending on patient’s life stage and comorbidities Allais et al. 2026.

Investigations should include thorough history taking emphasizing migraine characteristics, triggers, aura presence, hormonal influences (e.g., menstrual cycle, contraceptive use), and any new-onset symptoms during pregnancy, menopause, or oncological treatments. Risk stratification, including thrombotic risk assessment prior to estrogen-containing contraceptives, is essential to tailor safe therapeutic choices Allais et al. 2026.

Management emphasizes lifestyle and socio-behavioral interventions as first-line treatments in pediatric and adolescent females, with psychological support indicated when stress or psychiatric comorbidities are suspected. Pharmacologic therapy should be judiciously applied, with specialist involvement for complex cases Allais et al. 2026.

In adult women, migraine care must be adapted to the physiological transitions such as menstruation, pregnancy, assisted reproduction, menopause, and oncological therapies, ensuring continuity of care and early specialist referral. Safe pharmacological options and complementary therapies like acupuncture may be considered during pregnancy and breastfeeding. Hormone replacement therapy decisions require individualized migraine risk assessments Allais et al. 2026.

Further, digital health tools including telemedicine and shared digital platforms can strengthen multidisciplinary collaboration and continuity of care across community and specialist services Allais et al. 2026.

Overall, integrated personalized approaches involving accurate etiologic diagnosis, multidisciplinary collaboration, functional outcome focus, and patient-specific factors are paramount for optimal investigation and management Cantó-Cerdán and Cacho-Martínez P. 2026,Allais et al. 2026.