Differential Diagnosis

The patient's presentation of a right-sided headache with right eye pressure, stiff neck, and pain down the spine, along with a history of migraines and pituitary adenoma, suggests several potential diagnoses. These can be categorized as follows:

• Single Most Likely Diagnosis

  • Migraine with aura or complications: Given the patient's history of migraines, the current symptoms could represent a migraine episode, possibly with an aura (given the eye pressure) or complications that might involve the pituitary adenoma.

• Other Likely Diagnoses

  • Pituitary apoplexy: This condition occurs when there is sudden hemorrhage or infarction of the pituitary gland, often within a pre-existing adenoma. Symptoms can include sudden, severe headache, visual disturbances (which could be perceived as eye pressure), and neck stiffness.
  • Tension headache or cervicalgia: Although less specific, these conditions could contribute to or exacerbate the patient's symptoms, especially the headache and neck stiffness.
  • Idiopathic intracranial hypertension (IIH): This condition, also known as pseudotumor cerebri, can cause headaches, vision changes (including pressure), and neck stiffness, and might be considered in the context of a pituitary adenoma affecting intracranial pressure dynamics.

• Do Not Miss Diagnoses

  • Subarachnoid hemorrhage (SAH): Although less likely given the patient's history, a sudden, severe headache (often described as "the worst headache of my life") with neck stiffness is a classic presentation of SAH, which is a medical emergency.
  • Meningitis: Infection of the meninges can cause headache, neck stiffness, and pain radiating down the spine. While the patient's history might suggest other diagnoses, meningitis is a critical condition that must be ruled out.
  • Cervical spine instability or fracture: Especially if the pain down the spine is severe or accompanied by neurological deficits, an acute injury to the cervical spine must be considered.

• Rare Diagnoses

  • Pituitary stalk compression or other sellar/suprasellar lesions: Other than apoplexy, compression or lesions in this area could cause endocrine disturbances and visual field defects, among other symptoms.
  • Cranial nerve palsies: Direct involvement or compression of cranial nerves (e.g., III, IV, VI) by the pituitary adenoma could explain some of the patient's symptoms, such as eye pressure or vision changes.
  • Spinal cord lesions: Although less likely, lesions affecting the spinal cord could cause pain radiating down the spine and other neurological symptoms, depending on the location and nature of the lesion.