Differential Diagnosis

The patient's presentation is complex, with a history of chronic migraines and Chiari malformation, along with recent symptoms that suggest a possible new or ongoing issue. The differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Status Migrainosus or Intractable Migraine: Given the patient's history of chronic migraines and the description of her current headache as severe, persistent, and unresponsive to multiple analgesics, along with symptoms like blurry vision, this diagnosis seems highly plausible. The recent sinus infection could have triggered or exacerbated her migraine symptoms.
• Other Likely Diagnoses
  • Postural Orthostatic Tachycardia Syndrome (POTS): Symptoms such as frequent episodes of passing out, diaphoresis, temperature fluctuations, and insomnia could be indicative of POTS, especially in the context of recent illness and stress.
  • Sinusitis-related Headache: The CT scan showing paranasal sinusitis supports this diagnosis, as sinus infections can cause headaches that are severe and persistent, especially if the infection is not fully resolved.
  • Stress-related Exacerbation of Symptoms: The patient's significant stress due to her symptoms and family responsibilities could be exacerbating her condition, whether it's migraine, sinusitis, or another issue.
• Do Not Miss Diagnoses
  • Recurrent or Residual Chiari Malformation: Although the patient has undergone surgical treatment, there's a possibility of recurrence or residual symptoms, especially given her history and the nature of her current complaints.
  • Pseudotumor Cerebri (Idiopathic Intracranial Hypertension): This condition can present with symptoms similar to those described, including headache, vision changes (such as seeing triple), and can be a complication of steroid use or other factors.
  • Cerebral Venous Sinus Thrombosis: Although less likely given the CT scan results, this condition can present with headache, vision changes, and other neurological symptoms, and is important not to miss due to its potential for severe consequences.
• Rare Diagnoses
  • Ehlers-Danlos Syndrome: This genetic disorder can be associated with migraines, orthostatic intolerance (similar to POTS), and other symptoms the patient is experiencing. It's a less common condition but could explain a constellation of symptoms.
  • Occipital Neuralgia: This condition involves inflammation of the occipital nerves and can cause severe headache, often described as piercing or electric, which might fit the patient's description of "striking" pain.

Each of these diagnoses should be considered in the context of the patient's full medical history, recent treatments, and the results of diagnostic tests. Further evaluation, including potentially more specialized tests or consultations, may be necessary to determine the underlying cause of her symptoms.