Differential Diagnosis for Worsening Headaches in FTM on Testosterone

• Single most likely diagnosis:
  • Migraines or tension headaches exacerbated by hormonal changes: Testosterone therapy can lead to changes in headache patterns, including increased frequency or severity of migraines or tension headaches, due to hormonal fluctuations and potential effects on blood vessels and neurotransmitters.
• Other Likely diagnoses:
  • Polycythemia: Testosterone can increase red blood cell production, leading to polycythemia, which may cause headaches due to increased blood viscosity.
  • Hypertension: Testosterone therapy can also lead to increases in blood pressure, and uncontrolled hypertension is a common cause of headaches.
  • Sleep apnea: Testosterone can exacerbate or contribute to the development of sleep apnea, which is associated with morning headaches.
• Do Not Miss diagnoses:
  • Pituitary apoplexy: Although rare, this condition involves sudden hemorrhage or infarction of the pituitary gland and can be precipitated by hormonal changes. It presents with severe headache, visual disturbances, and acute endocrine deficiencies.
  • Subarachnoid hemorrhage or other intracranial hemorrhages: These are medical emergencies that can present with sudden, severe headache and require immediate attention.
  • Idiopathic intracranial hypertension (IIH): Also known as pseudotumor cerebri, this condition can be associated with hormonal changes and obesity, common in some transgender individuals. It presents with headache, vision changes, and papilledema.
• Rare diagnoses:
  • Cerebral venous sinus thrombosis: This is a rare condition that can be associated with polycythemia, dehydration, or other factors. It presents with headache, seizures, and neurological deficits.
  • Arteriovenous malformation (AVM) or arteriovenous fistula (AVF): These vascular anomalies can cause headaches and are usually congenital but may become symptomatic due to various factors, including hormonal changes.