Differential Diagnosis for Headache Types
The following table summarizes the characteristics of migraine headaches, tension headaches, and cluster headaches using the SOCRATES method (Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/relieving factors, Severity).
| Headache Type | Site | Onset | Character | Radiation | Associations | Time course | Exacerbating/relieving factors | Severity |
|---|---|---|---|---|---|---|---|---|
| Migraine | Unilateral | Gradual | Pulsating | May radiate | Nausea, vomiting, photophobia | Episodes lasting 4-72 hours | Triggers: stress, certain foods; relieved by rest, medication | Moderate to severe |
| Tension | Bilateral | Gradual | Dull, aching | No radiation | None | Episodes lasting 30 minutes to 7 days | Exacerbated by stress, relieved by massage, relaxation | Mild to moderate |
| Cluster | Unilateral, around the eye | Sudden | Excruciating, piercing | No radiation | Autonomic symptoms (e.g., nasal congestion, lacrimation) | Episodes lasting 15 minutes to 3 hours, occurring in clusters | No clear exacerbating or relieving factors | Severe |
Differential Diagnosis Categories
- Single Most Likely Diagnosis:
- Migraine headaches are often the most likely diagnosis for patients presenting with unilateral, pulsating headaches accompanied by nausea, vomiting, and photophobia.
- Other Likely Diagnoses:
- Tension headaches are likely in patients with bilateral, dull, aching headaches without significant associated symptoms.
- Cluster headaches are likely in patients with severe, unilateral headaches around the eye, accompanied by autonomic symptoms.
- Do Not Miss Diagnoses:
- Subarachnoid hemorrhage: Although unlikely, this diagnosis is critical to consider in patients with sudden, severe headaches (often described as "the worst headache of my life"), as it can be life-threatening if missed.
- Temporal arteritis: This condition, characterized by headaches, jaw claudication, and visual disturbances in older adults, requires prompt diagnosis to prevent complications like blindness.
- Rare Diagnoses:
- Trigeminal neuralgia: Characterized by sudden, severe, shock-like pain in the face, this condition is rare but important to consider in patients with unusual facial pain.
- Hemicrania continua: A rare headache disorder with continuous, unilateral pain and episodes of more severe pain, often accompanied by autonomic symptoms.
Justification for each diagnosis is based on the characteristic features outlined in the SOCRATES table and the potential consequences of missing a particular diagnosis. The single most likely diagnosis and other likely diagnoses are determined by the typical presentation of each headache type. Do not miss diagnoses are conditions that, although potentially less common, have significant morbidity or mortality if not promptly recognized and treated. Rare diagnoses, while less common, should be considered in patients with atypical presentations or when common diagnoses have been ruled out.