Differential Diagnosis for a 45-year-old Woman with a 6-hour Headache
Single Most Likely Diagnosis
- Tension headache: This is the most common type of headache and is often described as a band or a squeezing sensation around the forehead, usually bilateral, and of mild to moderate intensity. The short duration and lack of specific symptoms make this a plausible initial consideration.
Other Likely Diagnoses
- Migraine: Although migraines can present with a variety of symptoms, including severe headache, they are common in women and can occur without aura (warning signs). The headache can be unilateral or bilateral and is often accompanied by sensitivity to light, sound, or nausea, but these symptoms are not always present.
- Cluster headache: These are severe, usually unilateral headaches that occur in clusters or cycles, but they can occur at any time. They are less common in women but should be considered, especially if the headache is extremely painful and localized to one side of the head.
- Sinus headache: Headaches caused by sinusitis can be severe and are often accompanied by facial pain, nasal congestion, and fever. However, they can also present with headache alone, especially if the sinus infection is not fully developed.
Do Not Miss Diagnoses
- Subarachnoid hemorrhage: Although less likely given the short duration and lack of severe symptoms, a subarachnoid hemorrhage (bleeding into the space surrounding the brain) is a medical emergency that can present with a sudden, severe headache (often described as "the worst headache" of the patient's life). It's crucial to consider this diagnosis due to its high mortality and morbidity if missed.
- Meningitis: Inflammation of the protective membranes covering the brain and spinal cord, which can be life-threatening if not treated promptly. Symptoms can include headache, fever, and stiff neck, but early on, the presentation might be more subtle.
- Temporal arteritis: An inflammation of the blood vessels in the head, which can cause severe headache, usually unilateral, and is more common in older adults. It's a "do not miss" diagnosis because it can lead to blindness if not treated.
Rare Diagnoses
- Pituitary apoplexy: A rare condition caused by bleeding into the pituitary gland, which can present with sudden, severe headache, often accompanied by visual disturbances, but these might not always be present.
- Idiopathic intracranial hypertension (IIH): Also known as pseudotumor cerebri, this condition involves increased pressure within the skull without any obvious cause. It can cause headache, vision changes, and is more common in obese women of childbearing age.
- Cervicogenic headache: A headache that originates from the cervical spine, often due to a specific neck joint or muscle issue. While not as common as other headache types, it should be considered, especially if there's a history of neck injury or strain.