Differential Diagnosis for Severe Migraines

The patient presents with severe migraines, dizziness, and a history of headaches that are pounding/pulsating in nature, without nausea or vomiting. The headaches are constant throughout the day, with some fluctuation, and occur at random times, including during school and practice. Given the information, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Tension-Type Headache or Migraine: The patient's description of pounding/pulsating headaches, dizziness, and the lack of nausea/vomiting, along with a family history of headaches, suggests a primary headache disorder. The fact that the headaches are constant and occur at random times, including during physical activity like soccer practice, supports this diagnosis. The patient's use of Advil before a game might indicate an attempt to manage these headaches, which are common in individuals with a family history of migraines or tension-type headaches.
• Other Likely Diagnoses
  • Concussion or Post-Concussive Syndrome: Given the patient's history of hitting a soccer ball with his head, a concussion or post-concussive syndrome should be considered, especially with symptoms of dizziness. However, the lack of a reported injury or balance issues makes this less likely.
  • Allergic or Sinus Headaches: Although the patient takes allergy medication seasonally, the constant nature of the headaches and the lack of specific allergic or sinus symptoms (like nasal congestion or itchiness) make this less likely. However, it cannot be ruled out without further evaluation.
• Do Not Miss Diagnoses
  • Subarachnoid Hemorrhage or Other Intracranial Bleeds: Although rare and less likely given the patient's presentation and lack of severe symptoms like sudden severe headache, vomiting, or loss of consciousness, it's crucial to consider due to its potentially fatal outcome.
  • Brain Tumor: Any new or changing headache pattern, especially in a child or adolescent, warrants consideration of a brain tumor, despite being rare. The constant nature of the headaches and the absence of other neurological deficits make this less likely but not impossible.
  • Idiopathic Intracranial Hypertension (IIH): This condition, also known as pseudotumor cerebri, can cause headaches that are worse in the morning, with transient visual obscurations, and sometimes papilledema. Although the patient denies nausea/vomiting and visual disturbances, IIH should be considered, especially if there are other signs like obesity or recent weight gain, which are not mentioned.
• Rare Diagnoses
  • Chiari Malformation: A structural defect in the cerebellum that can cause headaches, especially with coughing or straining, and other neurological symptoms. The patient's symptoms do not strongly suggest this, but it remains a rare possibility.
  • Temporal Arteritis or Other Vasculitides: These conditions are rare in adolescents and typically present with more systemic symptoms like fever, weight loss, and jaw claudication, in addition to headaches. They are unlikely given the patient's age and presentation but should be considered in the differential diagnosis of headaches with an atypical presentation.