Differential Diagnosis for Chronic Daily Headaches

The patient's history of chronic daily headaches with a pressing sensation, worsened by sitting or standing, and persistent throughout the day, suggests a complex headache disorder. The lack of response to various treatments, including Aimovig, Emgality, Ajovy, Nurtec, Ubrelvy, Botox, and neuromodulation devices, indicates a challenging case. Here is a differential diagnosis organized into categories:

• Single Most Likely Diagnosis

  • Chronic Migraine: Given the patient's description of a pressing sensation on her head, worsening as the day progresses, and the initial response to Botox injections, chronic migraine is a strong consideration. The return of headaches after spinal fusion surgery could be related to changes in cervical spine mechanics or medication overuse headache.

• Other Likely Diagnoses

  • Medication Overuse Headache: The patient has tried multiple medications, which could contribute to medication overuse headache, especially if she is taking them frequently.
  • Cervicogenic Headache: The worsening of headaches with sitting or standing and the history of spinal fusion surgery suggest a possible cervicogenic component.
  • New Daily Persistent Headache (NDPH): The sudden onset of daily headaches two and a half years ago could fit the criteria for NDPH, although the lack of effectiveness of various treatments makes this less likely.

• Do Not Miss Diagnoses

  • Subarachnoid Hemorrhage or Other Intracranial Bleed: Although the patient's headaches are chronic, it's essential to rule out a secondary cause, such as an intracranial bleed, especially if there are any "thunderclap" headache episodes or accompanying symptoms like fever, confusion, or focal neurological deficits.
  • Brain Tumor: A brain tumor could cause chronic headaches, especially if there are associated symptoms like seizures, focal neurological deficits, or personality changes.
  • Temporal Arteritis: This condition, more common in older adults, can cause chronic headaches and should be considered, especially if there are accompanying symptoms like jaw claudication, visual disturbances, or polymyalgia rheumatica.

• Rare Diagnoses

  • Hemicrania Continua: A rare headache disorder characterized by a continuous, unilateral headache with exacerbations, which could be considered given the patient's persistent headache.
  • Trigeminal Neuralgia: Although typically characterized by episodic, severe pain, some forms of trigeminal neuralgia could present with more continuous pain and should be considered, especially if there are triggers or accompanying facial pain.
  • Chiari Malformation: A structural defect in the cerebellum that can cause chronic headaches, especially with coughing, sneezing, or straining, which might be considered given the patient's history of spinal fusion surgery and persistent headaches.