Differential Diagnosis for Migraine vs Tension Headache
When differentiating between migraine and tension headache, it's crucial to consider various factors, including the nature of the pain, accompanying symptoms, and potential triggers. Here's a structured approach to the differential diagnosis:
Single Most Likely Diagnosis
- Migraine: This is often considered the single most likely diagnosis when the headache is characterized by unilateral, throbbing pain, accompanied by symptoms such as nausea, vomiting, photophobia, and phonophobia. The presence of an aura (neurological symptoms that occur before the headache) further supports this diagnosis.
- Tension Headache: If the headache is described as bilateral, band-like pressure around the head, without the severe symptoms associated with migraines, tension headache becomes the more likely diagnosis.
Other Likely Diagnoses
- Cluster Headache: Characterized by severe, unilateral orbital or periorbital pain, often accompanied by autonomic symptoms like lacrimation and nasal congestion. The episodic nature and specific location of pain can help differentiate it from migraines and tension headaches.
- Sinus Headache: Pain and pressure in the face, particularly in the areas of the sinuses, often accompanied by nasal congestion and discharge. This diagnosis should be considered if there are signs of sinus infection or inflammation.
- Medication Overuse Headache: Headaches that occur due to the overuse of headache medications, leading to a vicious cycle of headache and medication use. This should be suspected in patients with a history of frequent or excessive use of pain relievers.
Do Not Miss Diagnoses
- Subarachnoid Hemorrhage: A life-threatening condition caused by bleeding into the space surrounding the brain. Although rare, it presents with a sudden, severe headache (often described as "the worst headache of my life") and can be accompanied by loss of consciousness, seizures, or other neurological deficits.
- Meningitis: Inflammation of the protective membranes covering the brain and spinal cord, which can be caused by infection. Symptoms include severe headache, fever, stiff neck, and altered mental status.
- Temporal Arteritis: Inflammation of the blood vessels in the head, particularly affecting the temporal artery. It's more common in older adults and can cause severe headache, jaw claudication, and visual disturbances, including blindness if not promptly treated.
- Brain Tumor: Although rare, a brain tumor can cause headaches, often accompanied by other neurological symptoms such as seizures, confusion, or focal neurological deficits.
Rare Diagnoses
- Trigeminal Neuralgia: A chronic pain condition that affects the trigeminal nerve, causing intense shock-like or stabbing pain in parts of the face.
- Occipital Neuralgia: Inflammation of the occipital nerves, leading to pain in the back and side of the head.
- Hypnic Headache: A rare headache disorder that occurs in older adults, characterized by recurrent headaches that awaken the patient from sleep.
Each of these diagnoses has distinct characteristics and accompanying symptoms that can help guide the differential diagnosis. A thorough history, physical examination, and, when necessary, diagnostic tests are crucial for accurately diagnosing the cause of headache and initiating appropriate treatment.