Management of Incidental Partially Empty Sella in a Patient with Headache

Understanding Empty Sella

Urgent workup is not necessary for a patient with headache and an incidental finding of partially empty sella when there is no history or symptoms of pituitary dysfunction, as recommended by the American College of Radiology 1, 2
Partially empty sella is typically an incidental finding on imaging studies performed for unrelated reasons, such as headache evaluation, with approximately 30% of patients with empty sella demonstrating some hypopituitarism upon testing, although most remain asymptomatic 1, 2

Key symptoms that would warrant more urgent evaluation include visual changes, signs of hormonal deficiencies such as fatigue, cold intolerance, or sexual dysfunction, according to the Journal for ImmunoTherapy of Cancer 3
The absence of symptoms suggesting pituitary dysfunction indicates that the partially empty sella finding is likely unrelated to the patient's headache 1

Basic hormonal screening, including thyroid function tests, morning cortisol and ACTH, and sex hormones, should be performed to rule out central hypothyroidism and assess adrenal axis, as recommended by the Journal for ImmunoTherapy of Cancer 3
MRI is the preferred imaging modality for characterizing empty sella, and no additional urgent imaging is needed if MRI already confirms partially empty sella without other concerning features, according to the American College of Radiology 1, 4

Attributing headache symptoms directly to empty sella without considering more common headache etiologies should be avoided, and unnecessary urgent tests that won't change immediate management should not be ordered, as recommended by the American College of Radiology 1
Missing rare but important hormonal deficiencies by not performing appropriate screening should also be avoided, according to the Journal for ImmunoTherapy of Cancer 3

MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluation of empty sella and can confirm the diagnosis even without IV contrast, as recommended by the American College of Radiology 5

Basic hormonal screening should include thyroid function tests, morning cortisol and ACTH, sex hormones, and prolactin levels, with the American College of Radiology and other societies suggesting that thyroid-stimulating hormone, T3, and T4 deficiencies are seen in up to 48% of cases, and elevated prolactin levels in approximately 28% of cases 6
Endocrinology referral is indicated if any hormonal abnormalities are detected on screening, or if the patient has symptoms suggestive of pituitary dysfunction, such as fatigue, cold intolerance, or sexual dysfunction, with the Journal for ImmunoTherapy of Cancer suggesting referral for these cases 6
Ophthalmology referral should be considered if visual symptoms are present, or if there are concerns about increased intracranial pressure or optic chiasm compression is noted on imaging, as suggested by the American College of Radiology and the Journal for ImmunoTherapy of Cancer 5, 6

All adults with an incidentally identified partially empty sella should undergo comprehensive hormonal screening regardless of symptoms, because approximately 30‑40 % demonstrate hypopituitarism on testing, with individual axis involvement often exceeding 10 % and potentially reaching 50 % 7