Differential Diagnosis for Mild Nonspecific White Matter Disease on MRI with Posterior Headaches

• Single most likely diagnosis:
  • Small vessel disease: This is a common cause of white matter changes on MRI, especially in older adults, and can be associated with headaches due to the involvement of small blood vessels in the brain.
• Other Likely diagnoses:
  • Migraines: Posterior headaches can be a symptom of migraines, and some studies suggest that white matter lesions may be more common in individuals with migraines.
  • Chronic tension headaches: Similar to migraines, chronic tension headaches could potentially be related to the white matter changes, though the direct link is less clear.
  • Multiple sclerosis (early or mild form): Although MS typically presents with more specific lesions, early or mild cases might only show nonspecific white matter changes, and headaches can be a symptom.
• Do Not Miss diagnoses:
  • Vasculitis (e.g., primary central nervous system vasculitis): This is a serious condition that can cause white matter changes and headaches. Missing this diagnosis could lead to severe consequences, including stroke or death.
  • CNS lymphoma: Although rare, CNS lymphoma can present with nonspecific white matter changes on MRI and requires prompt diagnosis and treatment.
  • Infectious diseases (e.g., neurosyphilis, Lyme disease): Certain infections can cause white matter changes and headaches, and missing these diagnoses could lead to significant morbidity or mortality.
• Rare diagnoses:
  • Leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation (LBSL): A rare genetic disorder that affects the brain's white matter.
  • Mitochondrial disorders: Some mitochondrial disorders can cause white matter changes on MRI, though they are rare and often present with a broader range of systemic symptoms.
  • Susac syndrome: A rare condition characterized by small vessel occlusions in the brain, retina, and inner ear, which can cause white matter changes and headaches.