Differential Diagnosis for a 46-year-old Female with Headache
The patient presents with a headache for the last 6 days, accompanied by neck pain, blurry vision, and photosensitivity, following a fall and loss of consciousness. Considering her history and symptoms, the differential diagnosis can be categorized as follows:
- Single most likely diagnosis
- Post-Concussive Syndrome: Given the patient's recent fall, loss of consciousness, and symptoms such as headache, neck pain, blurry vision, and photosensitivity, post-concussive syndrome is a strong consideration. This condition often occurs after a traumatic brain injury and can present with a variety of symptoms, including headaches that are worse than the patient's typical migraines.
- Other Likely diagnoses
- Post-Traumatic Migraine: The patient's history of migraines and the current symptoms could suggest a post-traumatic migraine, exacerbated by the recent fall.
- Cervicogenic Headache: Neck pain and headache following a fall could indicate a cervicogenic headache, where the pain is referred from the cervical spine to the head.
- Whiplash-Associated Disorder: Although the primary complaint is headache, the mechanism of injury (fall) could also result in whiplash, leading to a variety of symptoms including headache, neck pain, and visual disturbances.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Subdural Hematoma or Epidural Hematoma: Although less likely given the timeframe, these conditions are potentially life-threatening and must be considered, especially with a history of loss of consciousness and worsening symptoms.
- Subarachnoid Hemorrhage: This is another critical condition that, although less common, could present with sudden onset of severe headache (thunderclap headache) and requires immediate attention.
- Cervical Spine Fracture or Instability: Given the mechanism of injury, it's crucial to rule out any cervical spine injuries, which could be life-threatening if not promptly addressed.
- Rare diagnoses
- Arteriovenous Malformation (AVM) or Arterial Dissection: These vascular abnormalities could potentially cause headaches and other neurological symptoms, especially if the fall somehow affected or revealed an underlying condition.
- Chiari Malformation: This condition involves the cerebellum extending into the spinal canal and could cause headaches, neck pain, and visual disturbances, potentially exacerbated by a fall.
Workup/Scan in the Emergency Department
Given the patient's history of trauma, loss of consciousness, and worsening symptoms, the following workup/scans should be considered:
- CT Head: To rule out any acute hemorrhage, fracture, or other intracranial abnormalities.
- Cervical Spine Imaging (CT or MRI): To assess for any cervical spine injuries or instability.
- MRI Head: If the CT head is negative but clinical suspicion for other conditions (like post-concussive syndrome, migraines, or vascular abnormalities) remains high, an MRI might provide more detailed information.
- Neurological Examination: A thorough neurological exam is crucial to assess for any focal neurological deficits.
- Visual Acuity Test and Fundoscopic Exam: Given the complaint of blurry vision, assessing visual acuity and performing a fundoscopic exam can help identify any issues related to increased intracranial pressure or direct eye injury.
Each of these steps is aimed at systematically ruling out the more dangerous conditions while also considering the patient's overall clinical presentation to guide further management.