Differential Diagnosis for 72-year-old with Throbbing Headache

• Single most likely diagnosis
  • Migraine: The description of a throbbing headache that moves and is worst in the middle of the night, along with blurry vision, is consistent with migraine, especially given the absence of scalp tenderness which might suggest other diagnoses like temporal arteritis. The high blood pressure could be a contributing factor or a separate issue.
• Other Likely diagnoses
  • Tension Headache: Although the headache is described as throbbing, which is more typical of migraines, tension headaches can also cause significant discomfort and could be exacerbated by stress or high blood pressure.
  • Hypertension-related Headache: Given the patient's high blood pressure, it's possible that the headache is directly related to her hypertension, especially if her blood pressure is not well-controlled.
  • Cluster Headache: Although less common, cluster headaches can occur at any age and are known for their severe, one-sided pain, often waking patients from sleep. However, they typically involve autonomic symptoms like nasal congestion or eye watering, which are not mentioned.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Subarachnoid Hemorrhage (SAH): Although the patient's headache does not have the classic "thunderclap" onset, SAH can present with a variety of headache patterns, and missing this diagnosis could be catastrophic.
  • Temporal Arteritis: Despite the absence of scalp tenderness, temporal arteritis (giant cell arteritis) is a critical diagnosis to consider in older adults, especially with new-onset headache and visual symptoms, due to the risk of blindness if not promptly treated.
  • Pituitary Apoplexy: A rare but potentially life-threatening condition that could cause sudden headache and visual disturbances due to a hemorrhage or infarction of the pituitary gland.
• Rare diagnoses
  • Trigeminal Neuralgia: While this condition causes severe facial pain, it's less likely given the description of the headache moving from the forehead to the side and involving blurry vision.
  • Occipital Neuralgia: Involves pain in the distribution of the occipital nerves but is less likely given the headache's characteristics and the presence of blurry vision.
  • Idiopathic Intracranial Hypertension (IIH): Could cause headache and visual disturbances, including blurred vision, but typically presents with other symptoms like papilledema on exam, which is not mentioned.