Differential Diagnosis for Headaches

When diagnosing headaches, it's crucial to consider a wide range of potential causes to ensure appropriate treatment and follow-up. The differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Tension headaches: The most common type of headache, often described as a band or a squeezing sensation around the forehead, usually mild to moderate in intensity, and can be related to stress, poor posture, or muscle tension.
• Other Likely Diagnoses
  • Migraines: Characterized by severe, throbbing pain, often unilateral, and can be accompanied by nausea, vomiting, and sensitivity to light and sound.
  • Cluster headaches: Extremely painful, occur in clusters or cycles, and are often accompanied by nasal congestion and eye watering on the affected side.
  • Sinus headaches: Caused by inflammation or infection of the sinuses, leading to pain and pressure in the face and forehead.
• Do Not Miss Diagnoses
  • Subarachnoid hemorrhage: A life-threatening condition caused by bleeding into the space surrounding the brain, often presenting with a sudden, severe headache (thunderclap headache).
  • Meningitis: Inflammation of the protective membranes covering the brain and spinal cord, which can be caused by infection and presents with headache, fever, and stiff neck.
  • Temporal arteritis: Inflammation of the blood vessels in the temples, which can lead to blindness if not treated promptly, presenting with headache, jaw claudication, and visual disturbances.
  • Brain tumor: Although rare, can cause headaches due to increased intracranial pressure, often worse in the morning and accompanied by nausea and vomiting.
• Rare Diagnoses
  • Trigeminal neuralgia: A chronic pain condition that affects the trigeminal nerve, causing intense shock-like or stabbing pain in parts of the face.
  • Occipital neuralgia: Involves the occipital nerves and can cause pain in the back and side of the head.
  • Hypnic headache: A rare type of headache that occurs only during sleep and wakes the patient up.

Justification

Each diagnosis is considered based on the typical presentation, risk factors, and potential consequences of missing the diagnosis. Tension headaches are the most common, while migraines and cluster headaches have distinct features that aid in diagnosis. The "Do Not Miss" category includes conditions that are less common but potentially life-threatening or leading to significant morbidity if not promptly recognized and treated. Rare diagnoses, although less likely, should be considered in patients who do not fit into the more common categories or have atypical presentations.

Treatment and Follow-Up

Treatment varies widely depending on the diagnosis, ranging from over-the-counter pain relievers for tension headaches to more specific treatments like triptans for migraines and oxygen therapy for cluster headaches. For conditions in the "Do Not Miss" category, immediate medical attention is required, often involving neuroimaging, lumbar puncture, or other diagnostic tests to confirm the diagnosis. Follow-up care should be tailored to the specific diagnosis, with regular check-ins for chronic conditions and urgent reevaluation for any signs of worsening or new symptoms.

When to Send to Neurology

Referral to a neurologist is indicated for:

• Atypical headache presentations
• Sudden onset or severe headaches
• Headaches accompanied by neurological deficits (e.g., weakness, numbness, vision changes)
• Failure to respond to initial treatment
• Presence of red flags such as fever, stiff neck, or confusion
• Suspected secondary headaches due to underlying conditions like brain tumors or vascular malformations

Early recognition and appropriate referral can significantly impact the management and outcome of headache disorders.