Differential Diagnosis for New Onset Unilateral Headache in a 52-Year-Old Male
Single Most Likely Diagnosis
- Tension-Type Headache: This is the most common type of headache and can present unilaterally, especially if the patient has a history of stress, poor posture, or muscle tension. The age and new onset could also suggest a secondary cause, but initially, tension-type headache is a common consideration.
- Migraine: Although migraines often start at a younger age, it's not uncommon for them to begin in adulthood. A unilateral headache with or without aura could be indicative of a migraine, especially if accompanied by other migraine features like photophobia, phonophobia, or nausea.
Other Likely Diagnoses
- Cluster Headache: These are severe, unilateral headaches that occur in clusters or cycles, often waking the patient from sleep. They are more common in men and can start at any age, including in the fifth decade.
- Temporal Arteritis (Giant Cell Arteritis): While more common in older individuals, temporal arteritis can present with new onset unilateral headache, especially if accompanied by jaw claudication, visual disturbances, or polymyalgia rheumatica symptoms.
- Trigeminal Neuralgia: This condition involves sudden, severe, shock-like pain around the eyes, lips, or nose mainly because of abnormal blood vessels pressing on the trigeminal nerve in the head. It's more common in older adults and can present unilaterally.
Do Not Miss Diagnoses
- Subarachnoid Hemorrhage: Although less common, a sudden, severe unilateral headache (often described as "the worst headache of my life") could be indicative of a subarachnoid hemorrhage, which is a medical emergency.
- Stroke or Transient Ischemic Attack (TIA): Headache can be a presenting feature of stroke or TIA, especially if accompanied by other neurological deficits such as weakness, numbness, or difficulty with speech.
- Intracranial Aneurysm or Arteriovenous Malformation (AVM): These vascular abnormalities can cause headaches and are critical to diagnose due to their potential for rupture or bleeding.
- Meningitis or Encephalitis: Infection or inflammation of the meninges or brain can present with headache, fever, and other systemic symptoms, requiring prompt diagnosis and treatment.
Rare Diagnoses
- Hemicrania Continua: A rare, continuous, unilateral headache that is responsive to indomethacin.
- Primary Thunderclap Headache: A very severe headache that reaches its maximum intensity within a minute, often described as "the worst headache of my life."
- Cervicogenic Headache: Headache referred from the cervical spine, often accompanied by neck pain and limited range of motion.
- Pituitary Apoplexy: A rare condition involving hemorrhage or infarction of the pituitary gland, presenting with sudden, severe headache, often accompanied by visual disturbances and acute endocrine deficiencies.
Workup
The workup for new onset unilateral headache in a 52-year-old male should include:
- Detailed history to identify potential triggers, associated symptoms, and risk factors for secondary causes.
- Physical examination, including neurological and ophthalmological assessments.
- Laboratory tests (e.g., ESR, CRP) if temporal arteritis is suspected.
- Imaging studies (e.g., MRI of the brain) to rule out structural causes such as aneurysms, AVMs, or tumors.
- Consideration of a lumbar puncture if meningitis or subarachnoid hemorrhage is suspected.