Differential Diagnosis for CVA and Complicated Migraine

When differentiating between Cerebrovascular Accident (CVA) and complicated migraine, physical examination (PE) findings play a crucial role. Here's a categorized differential diagnosis to consider:

• Single Most Likely Diagnosis
  • CVA (Stroke): This is often the primary concern due to its high morbidity and mortality. Key PE findings include sudden onset of focal neurological deficits such as hemiparesis, facial droop, speech difficulties, and visual field defects. The presence of these signs, especially if they are persistent, strongly suggests a CVA.
• Other Likely Diagnoses
  • Complicated Migraine: Characterized by neurological symptoms that can mimic those of a CVA, such as aura symptoms (visual, sensory, or motor), but these are typically transient and reversible. PE findings might include photophobia, phonophobia, and sometimes focal neurological deficits that resolve within 60 minutes.
  • Transient Ischemic Attack (TIA): Often considered a "mini-stroke," TIAs present with temporary neurological symptoms similar to those of a CVA but resolve within 24 hours. PE findings are similar to those of CVA but are transient.
• Do Not Miss Diagnoses
  • Subarachnoid Hemorrhage: Although less common, this condition can present with sudden, severe headache (often described as "the worst headache of my life") and may have accompanying neurological deficits. It's crucial to consider this diagnosis due to its high mortality rate if not promptly treated.
  • Venous Sinus Thrombosis: This condition can present with headache, seizures, and focal neurological signs. It's particularly important to consider in patients with risk factors such as hypercoagulable states or dehydration.
  • Arterial Dissection: Can lead to either ischemic or hemorrhagic stroke and may present with neck pain and neurological deficits. It's a critical diagnosis to not miss due to its potential for severe consequences.
• Rare Diagnoses
  • Cerebral Vasculitis: Inflammation of the blood vessels in the brain, which can cause a wide range of neurological symptoms including headache, seizures, and focal deficits. It's rare but important to consider in patients with systemic symptoms or known autoimmune diseases.
  • Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes (MELAS): A rare genetic disorder that can cause stroke-like episodes, often with a headache and seizures. It's crucial to consider in young patients with recurrent, unexplained neurological events.

Each of these diagnoses has distinct PE findings and implications for management, emphasizing the importance of a thorough physical examination and diagnostic workup to differentiate between them accurately.