Differential Diagnosis

The patient's symptoms of periodic episodes with decreased vision followed by a throbbing occipital headache can be analyzed as follows:

• Single most likely diagnosis

  • a. Migraine: This is the most likely diagnosis due to the characteristic visual aura (decreased vision) followed by a throbbing headache, which is a common presentation of migraine with aura. The location of the headache in the occipital region and its throbbing nature also align with migraine characteristics.

• Other Likely diagnoses

  • b. Vertebral-basilar insufficiency: Although less likely, this condition can cause visual disturbances and headaches due to transient ischemic attacks in the posterior circulation. However, it is more commonly associated with other symptoms such as vertigo, dysarthria, and ataxia.
  • d. Panic attack: While panic attacks can cause a variety of symptoms including visual disturbances and headaches, they are typically accompanied by other symptoms such as palpitations, sweating, and a fear of losing control or dying, which are not mentioned in the scenario.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Vertebral artery dissection: This is a serious condition that can present with headache and visual disturbances. Although it is less common, missing this diagnosis could have severe consequences, including stroke.
  • Posterior reversible encephalopathy syndrome (PRES): This condition can cause visual disturbances, headaches, and seizures due to posterior cerebral edema. It is often associated with hypertension, eclampsia, or certain medications.

• Rare diagnoses

  • Occipital lobe seizures: These can cause visual auras and headaches but are less common and typically associated with other seizure activity.
  • Chiari malformation: This structural anomaly can cause headaches and visual disturbances, especially with coughing or straining, but is less likely to present with the exact symptoms described.