Differential Diagnoses for Migraine Headache

When considering the differential diagnoses for a migraine headache, it's crucial to categorize potential causes based on their likelihood and the severity of their consequences if missed. The following categorization helps in systematically approaching the diagnosis:

• Single Most Likely Diagnosis

  • Migraine headache itself: This is the most likely diagnosis given the presentation of migraine symptoms such as unilateral headache, photophobia, phonophobia, and sometimes aura. The justification for this being the single most likely diagnosis is based on the prevalence and the characteristic symptoms that often point directly to migraine.

• Other Likely Diagnoses

  • Tension headache: Often presents with bilateral headache and may mimic migraine in some aspects but typically lacks the severe intensity and associated symptoms like aura.
  • Cluster headache: Known for its severe, unilateral orbital or periorbital pain, often accompanied by autonomic symptoms like lacrimation and nasal congestion.
  • Sinus headache: Headache associated with sinusitis, which can present with facial pain and pressure, but is usually accompanied by other symptoms like nasal congestion and fever.
  • Medication overuse headache: A condition where frequent use of headache medications leads to worsening headache frequency and intensity.

• Do Not Miss Diagnoses

  • Subarachnoid hemorrhage: A life-threatening condition that presents with a sudden, severe headache (often described as "the worst headache of my life"), which could be mistaken for a migraine. The severity and sudden onset are key distinguishing features.
  • Meningitis: Inflammation of the protective membranes covering the brain and spinal cord, which can present with headache, fever, and stiff neck.
  • Temporal arteritis: An inflammation of the blood vessels in the head, which can cause headache, visual disturbances, and jaw claudication, particularly in older adults.
  • Brain tumor: Although rare, a brain tumor can cause headaches that may resemble migraines, especially if the tumor increases intracranial pressure.

• 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 irritation of the occipital nerves, leading to pain in the back and side of the head.
  • Hypnic headache: A rare headache disorder that occurs only during sleep and wakes the patient up.
  • Thunderclap headache: A very severe headache that reaches its maximum intensity within a minute, often indicative of a subarachnoid hemorrhage but can have other causes as well.

Each of these diagnoses has distinct features and justifications for inclusion in the differential diagnosis of migraine headache, emphasizing the importance of a thorough clinical evaluation to accurately diagnose and manage the condition.