Differentials
Migraine
SIGNS / SYMPTOMS
Repeated attacks of severe unilateral or bilateral throbbing or pressure pain. Pain lasts at least 4 hours without treatment (compared with 15 to 180 minutes for cluster headache). Prominent associated features of migraine include exacerbation of pain with routine physical activity resulting in motion sensitivity (by contrast with cluster headache, where restlessness is common), nausea and vomiting, photophobia (often bilateral), and phonophobia. Approximately 1 in 3 patients have an aura with their headache and these can consist of visual, sensory, motor, or speech disturbance. Autonomic features can be seen but tend to be bilateral and less prominent than in cluster headache. Triggers may include alcohol (delayed response of several hours), caffeine, some foodstuffs, sleep deprivation or excess, hunger, dehydration, bright lights, weather changes, high altitude, and strong smells. Oxygen does not have a dramatic effect on the pain, and it often responds well to oral triptans. A family history of migraine is seen in many patients.
INVESTIGATIONS
There are no distinguishing diagnostic tests, although a complete response to high-flow oxygen is unusual.
Paroxysmal hemicrania
SIGNS / SYMPTOMS
Signs and symptoms are similar to those of cluster headache, with severe unilateral orbital, periorbital, or temporal pain (or any combination of these sites), and ipsilateral autonomic symptoms of the eye and nose. Attacks are three times more common in women than in men; shorter (2 minutes to 30 minutes) and more frequent (between 1 and 40 per day) than cluster headache; and respond to indomethacin. Attacks can be episodic or chronic.[2]
INVESTIGATIONS
Completely responds to indomethacin.
Short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
SIGNS / SYMPTOMS
At least 20 attacks of: moderate or severe unilateral head pain with orbital, periorbital, temporal, or other trigeminal distribution; occurring as single stabs, series of stabs, or in a saw-tooth pattern; lasting for 1 to 600 seconds; accompanied by ipsilateral lacrimation and conjunctival injection; occurring at least once a day.[2]
INVESTIGATIONS
There are no distinguishing diagnostic tests.
Trigeminal neuralgia
SIGNS / SYMPTOMS
Recurrent paroxysms of brief, intense, unilateral pain that is electric-shock-like, shooting, stabbing, or sharp, lasting from a fraction of a second to 2 minutes, usually affecting one or more divisions of the trigeminal nerve, with no radiation beyond. Typically, trigeminal neuralgia pain is in the V2-V3 distribution, whereas cluster attacks are more commonly in the V1 distribution (periorbital). Mechanical triggers for attacks may include shaving, smoking, talking, brushing teeth, and eating. Attacks are stereotyped in the individual patient. Pain often evokes spasms of facial muscles on the affected side (tic douloureux).[2]
INVESTIGATIONS
There are no distinguishing diagnostic tests.
Cluster-tic syndrome
SIGNS / SYMPTOMS
Symptoms of both cluster headache and trigeminal neuralgia. Both conditions need to be treated.[2]
INVESTIGATIONS
There are no distinguishing diagnostic tests.
Hemicrania continua
SIGNS / SYMPTOMS
Persistent, strictly unilateral headache that lasts for at least 3 months and responds to indomethacin. Headache is of moderate intensity with exacerbations of severe pain. At least one ipsilateral autonomic feature is usually present.[2]
INVESTIGATIONS
Complete response to indomethacin.
Angle-closure glaucoma
SIGNS / SYMPTOMS
Severe pain, usually unilateral, in the region of the eye due to elevated intraocular pressure. Other symptoms include nausea, blurred vision, corneal edema, and redness of the eye.[2]
INVESTIGATIONS
Tonometry shows elevated intraocular pressure.
Gonioscopy shows narrow angles.
Eye exam shows reduced visual acuity; a semi-dilated, fixed pupil; a cloudy cornea; and optic disc changes.
Headache attributed to disorder of the nose or paranasal sinuses
SIGNS / SYMPTOMS
Also known as "sinus headache". Other symptoms and/or clinical signs of the disorder are apparent: for example, thick, discolored nasal mucus, decreased sense of smell, and pain in one cheek or upper teeth.[2] Headaches due to sinus disease often last days or longer.
INVESTIGATIONS
CT sinus may demonstrate acute rhinosinusitis.
Hypnic headache
SIGNS / SYMPTOMS
Dull headache that occurs only during sleep and causes awakening. Occurs on >10 days per month for >3 months; lasts from 15 minutes up to 4 hours after waking; with no cranial autonomic features. Pain is bilateral in two-thirds of cases, is usually mild to moderate, and can be treated with caffeine or lithium prior to bedtime. Onset is usually after age 50 years.[2]
INVESTIGATIONS
There are no distinguishing diagnostic tests.
Subarachnoid hemorrhage
SIGNS / SYMPTOMS
Sudden onset of intense and incapacitating headache, accompanied by nausea, vomiting, altered consciousness, and nuchal rigidity.[2]
INVESTIGATIONS
MRI or CT scan without contrast has >90% sensitivity in the first 24 hours. Lumbar puncture should be performed if neuroimaging has not provided the diagnosis.
Giant cell arteritis
SIGNS / SYMPTOMS
Pain and tenderness over the temporal artery, which might occur with loss of vision. Pain resolves within 3 days of high-dose corticosteroid treatment.[2]
INVESTIGATIONS
Erythrocyte sedimentation rate >50 mm/hour and elevated CRP seen in the majority of patients. Duplex scanning of temporal arteries might reveal thickening of the arterial wall. Temporal artery biopsy shows granulomatous inflammation with multinucleated giant cells within the internal elastic lamina.[28]
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