Differentials
Tension-type headache
SIGNS / SYMPTOMS
A mild headache that tends not to interfere with school and leisure activities.
It is less likely to lead to a physician visit.
Often described as tightness in a band-like distribution.
It may coexist with migraine.
Nausea, vomiting, photophobia, and phonophobia are not associated with tension-type headache.[1]
INVESTIGATIONS
Detailed history. There are no confirmatory tests.
Medication-overuse headache
SIGNS / SYMPTOMS
Often associated with migraine, especially with chronic migraine.
A mild to moderate headache with onset at awakening and of several hours' duration.
It is rarely disabling.
It lacks typical migrainous features (vomiting, photophobia, and phonophobia).
More likely to develop with the chronic (more than 3 months) and frequent (more than 2-3 times a week) use of rescue drugs.[1]
INVESTIGATIONS
Detailed history. There are no confirmatory tests.
Post-traumatic headache
SIGNS / SYMPTOMS
Headache is often part of concussion following minor head trauma, and it might linger for days to weeks.
Its character is variable, and it might have migrainous features.
In patients with migraine, head trauma might worsen the migraine.
Headache onset is within 7 days from the head trauma.[1]
INVESTIGATIONS
Detailed history. There are no confirmatory tests.
Brain tumor
SIGNS / SYMPTOMS
Most often causes acute to subacute onset of progressive headache, sometimes associated with vomiting and double vision.
New findings on neurologic exam associated with progressive headache is an ominous sign.
INVESTIGATIONS
Brain MRI with and without contrast will identify a space-occupying lesion.
Idiopathic intracranial hypertension (IIH)
SIGNS / SYMPTOMS
A nonspecific, progressive headache of acute or subacute onset.
Often associated with signs and symptoms of increased intracranial pressure (blurry vision, double vision, vomiting, nocturnal headache, tinnitus, papilledema).
Tends to be associated with obesity, or with certain drugs.
INVESTIGATIONS
Brain MRI rules out other causes of increased intracranial pressure (such as a space-occupying lesion).
Brain MRI might identify subtle changes associated with IIH.
Lumbar puncture with measurement of the opening pressure establishes the increased intracranial pressure.
Lumbar puncture needs to be preceded by brain imaging to rule out a space-occupying lesion.
Central nervous system infection
SIGNS / SYMPTOMS
Progressive headache associated with fever.
Neck stiffness and other meningismus signs are often present.
Seizures or mental status changes suggest parenchymal involvement.
INVESTIGATIONS
Spinal fluid studies and culture are often abnormal and can identify the infectious agent.
Brain MRI with and without contrast identifies meningeal enhancement and/or parenchymal involvement suggestive of encephalitis.
Cerebral venous thrombosis
SIGNS / SYMPTOMS
Most cases occur in hospitalized patients who have central venous access.
Acute, nonspecific headache and signs of increased intracranial pressure (papilledema, double vision) are common initial symptoms.
Seizures and progressive neurologic signs suggest venous infarction, which is often hemorrhagic.
May mimic idiopathic intracranial hypertension in pediatric patients.
INVESTIGATIONS
Brain MRI with and without contrast often identifies cerebral venous thrombosis, although magnetic resonance venography is more sensitive.
Brain MRI with and without contrast identifies venous infarction.
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