Differential Diagnosis for Sudden Onset Headaches with Associated Symptoms

The symptoms described by the fiancé, including extremely intensely painful sudden onset headaches during heavy physical activity, weakness, blurred vision, and subsequent deep sleep, suggest a complex condition that has eluded diagnosis for years. The following differential diagnoses are categorized for consideration:

• Single Most Likely Diagnosis

  • Migraine with Aura: This condition is characterized by intense headaches that can be triggered by physical activity, accompanied by neurological symptoms such as visual disturbances (aura), weakness, and sometimes followed by a period of deep sleep. The variability in symptoms and triggers, as well as the absence of a clear diagnosis despite medical evaluations, could align with the complexities of migraine disorders.

• Other Likely Diagnoses

  • Exertional Headache: These are headaches specifically brought on by physical exertion, which could explain the onset during heavy activity. However, the additional symptoms of weakness and deep sleep might suggest a more complex condition.
  • Cluster Headaches: Although typically not triggered by physical activity, cluster headaches are extremely painful and can occur in cycles, potentially explaining the episodic nature of the symptoms.
  • Orthostatic Intolerance: This condition involves symptoms that occur upon standing, including headache, weakness, and visual disturbances, which could be exacerbated by physical activity.

• Do Not Miss Diagnoses

  • Subarachnoid Hemorrhage (SAH): Although less likely given the recurrent nature without a clear incident of severe trauma or sudden onset of "the worst headache" of one's life, SAH is a critical diagnosis to rule out due to its high mortality and morbidity.
  • Arteriovenous Malformation (AVM): AVMs can cause a variety of neurological symptoms, including headaches, and can be precipitated by physical activity. The risk of hemorrhage makes this a critical diagnosis not to miss.
  • Pituitary Apoplexy: A condition where the pituitary gland suddenly hemorrhages or becomes infarcted, leading to severe headache, visual disturbances, and potential loss of consciousness. It's a medical emergency.

• Rare Diagnoses

  • CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy): A rare hereditary condition leading to stroke and dementia, which could potentially cause migraine-like headaches among other symptoms.
  • Mitochondrial Myopathies: Conditions such as MELAS syndrome (Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes) can cause a variety of symptoms including headaches, weakness, and visual disturbances, especially triggered by physical exertion.

Given the complexity and the lack of diagnosis despite medical evaluations, a comprehensive approach including:

• Detailed neurological examination
• Advanced imaging (MRI, MRA of the brain)
• Possibly, a tilt-table test for orthostatic intolerance
• Sleep study to evaluate the deep sleep episodes
• Consideration of a headache or pain management specialist for further evaluation and treatment of potential migraine or other headache disorders

is recommended. The key to unlocking the diagnosis may lie in a meticulous history, including triggers, associated symptoms, and the pattern of these episodes over time, combined with a thorough and targeted diagnostic workup.