Differentials
Chronic migraine
SIGNS / SYMPTOMS
Routine movement aggravates migraine. History of episodic migraine. Increase in frequency to >15 headache days per month. Migraine is misdiagnosed as tension-type headache in up to 32% of patients.[21] The worsening of pain with activity, presence of nausea, and severe intensity is common with migraine and inconsistent with tension-type headache.
INVESTIGATIONS
Clinical diagnosis.
Medication overuse headache
SIGNS / SYMPTOMS
History of previous primary headache. Use of analgesics and ergotamine at a high frequency and worsening of headache on discontinuation of medication. Over several months, frequency and duration increases such that attacks become daily or near daily, although not necessarily more severe.
Opioids and barbiturate-containing analgesics most commonly produce this syndrome.
INVESTIGATIONS
Clinical diagnosis.
Sphenoid sinusitis
SIGNS / SYMPTOMS
Vertex or frontal pain, often described as pressure, but not necessarily with additional sinus symptoms.
INVESTIGATIONS
CT sinus to evaluate for acute or chronic sinusitis.
Giant cell arteritis
SIGNS / SYMPTOMS
Generally affects those over 50 years of age. New head pain associated with soreness of the scalp; associated with polymyalgia rheumatica and often jaw or tongue claudication. Cough is also common.
INVESTIGATIONS
Erythrocyte sedimentation rate and/or CRP typically significantly elevated.
Temporomandibular disorder (TMD)
SIGNS / SYMPTOMS
Pain over temporalis associated with noise and clicking over temporomandibular joint with jaw movement. Often associated with bruxism and limited jaw movements, or pain or locking of the jaw with opening of mouth.
INVESTIGATIONS
Clinical diagnosis.
Pituitary tumor
SIGNS / SYMPTOMS
Abnormal neurologic examination. Visual field defects and galactorrhea may occur.
INVESTIGATIONS
Apparent on brain MRI.
Brain tumor
SIGNS / SYMPTOMS
Abnormal neurologic examination including reflex asymmetry, sensory asymmetry, or motor weakness. Papilledema suggests an intracranial mass lesion.
INVESTIGATIONS
Apparent on brain MRI.
Chronic subdural hematoma
SIGNS / SYMPTOMS
Abnormal mentation, abnormal neurologic examination including reflex asymmetry, sensory asymmetry, or motor weakness.
INVESTIGATIONS
Apparent on brain MRI.
Idiopathic intracranial hypertension
SIGNS / SYMPTOMS
As well as papilledema, there may be reduced visual acuity, visual field defect (enlarged blind spot), or diplopia caused by a sixth nerve palsy. CSF pressures are abnormal and are increased to >200 mm water in nonobese and >250 mm water in obese people. Papilledema is usually noted.
INVESTIGATIONS
Normal MRI possibly with small ventricles; most important finding is elevated spinal fluid pressure on lumbar puncture.
Spontaneous intracranial hypotension
SIGNS / SYMPTOMS
Orthostatic headache which typically occurs within 15 minutes of sitting or standing and is relieved within minutes by lying down. Neurologic symptoms may or may not be present.
INVESTIGATIONS
Typical features on brain MRI (pachymeningeal enhancement or other findings suggestive of low CSF pressure such as tonsillar herniation or subdural collections); features suggestive of CSF leak on spinal MRI; low CSF pressure (<60 mm water) on lumbar puncture.
Cervical pathology
SIGNS / SYMPTOMS
Rarely, serious cervical pathology such as a herniated disk may contribute to headache.
INVESTIGATIONS
MRI scan reveals disk herniations and soft tissue masses.
Obstructive sleep apnea
SIGNS / SYMPTOMS
Presence of risk factors: older age, male sex, obesity, craniofacial and upper airway abnormalities, smoking, or family history of obstructive sleep apnea. History of daytime sleepiness, snoring, or apneas. Headaches typically occur on wakening and last several hours. They usually occur daily or most days of the week.
INVESTIGATIONS
Polysomnography is diagnostic.
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