Differential Diagnosis for 72-year-old Gentleman with Headache

The patient presents with a two-month history of headache that worsens with coughing and arising from chairs, suggesting an increase in intracranial pressure with Valsalva maneuvers. Given the unrevealing CT scan of the head and pending MRI, along with negative connective tissue cascade and normal inflammatory markers, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Idiopathic Intracranial Hypertension (IIH): This condition is characterized by increased intracranial pressure without a detectable cause, often presenting with headache that worsens with activities that increase intrathoracic pressure, such as coughing. The absence of sinusitis or mastoiditis and normal CT scan supports this consideration, although an MRI is crucial for confirmation and to rule out other causes.
• Other Likely Diagnoses
  • Cervicogenic Headache: Given the exacerbation of headache with arising from chairs, a cervicogenic cause should be considered, where the pain is referred from the cervical spine.
  • Chronic Daily Headache: This could be a primary headache disorder, but the specific triggers (coughing, arising from chairs) suggest a secondary cause that needs to be investigated.
  • Spontaneous Intracranial Hypotension: Although less common, this condition can present with headache that worsens with standing, due to a leak of cerebrospinal fluid.
• Do Not Miss Diagnoses
  • Brain Tumor: Although the CT scan was unrevealing, certain tumors, especially those in the posterior fossa or sellar region, might not be visible on CT. An MRI is essential for ruling out this potentially life-threatening condition.
  • Subarachnoid Hemorrhage or Other Vascular Malformations: These conditions can sometimes present with atypical headache patterns and might not always be evident on a non-contrast CT scan, especially if the bleed is small or chronic.
  • Infectious or Inflammatory Conditions: Despite the lack of evidence for sinusitis or mastoiditis and normal inflammatory markers, rare or chronic infections (e.g., neurosyphilis, Lyme disease) or inflammatory conditions (e.g., sarcoidosis, vasculitis) could present with headache and should be considered, especially if other symptoms or risk factors are present.
• Rare Diagnoses
  • Chiari Malformation: This condition involves herniation of the cerebellar tonsils into the spinal canal, which can cause headache, especially with coughing or straining.
  • Pseudotumor Cerebri Syndrome due to Other Causes: Certain medications, hormonal changes, or other systemic conditions can lead to increased intracranial pressure without an apparent cause on initial evaluation.

Further Testing Needed

• MRI of the Head: To rule out structural abnormalities, including tumors, vascular malformations, and conditions affecting the brain and meninges.
• MRI of the Cervical Spine: If cervicogenic headache is suspected, to evaluate the cervical spine for any abnormalities.
• Lumbar Puncture: To measure cerebrospinal fluid pressure and analyze the fluid for signs of infection, inflammation, or hemorrhage, especially if IIH or spontaneous intracranial hypotension is suspected.
• Blood Tests: Further serological tests for infectious or inflammatory conditions if clinically indicated.
• Neurological Examination: A comprehensive neurological examination by a neurologist to assess for any focal neurological deficits or signs of increased intracranial pressure.