Differential Diagnosis for Headache with Normal Blood Pressure and No Relief from Pain Medication

• Single Most Likely Diagnosis
  • Tension headache: This is the most common type of headache and is often described as a band or a squeezing sensation around the forehead, usually bilateral. The fact that the blood pressure is normal and pain medication does not provide relief suggests a non-vascular and possibly muscular origin, aligning with tension headache characteristics.
• Other Likely Diagnoses
  • Migraine: Although migraines can be severe and typically unilateral, some patients may experience bilateral pain. The lack of relief from standard pain medication could be due to the specific pathophysiology of migraines, which often requires more targeted therapy like triptans.
  • Sinus headache: Headaches caused by sinusitis can be severe and not responsive to typical pain relievers. The pain is usually facial and can be accompanied by other symptoms like nasal congestion and fever.
  • Cluster headache: These are extremely painful headaches that occur in clusters or cycles, often waking the patient from sleep. They are usually unilateral and can be accompanied by autonomic symptoms like nasal congestion or eye watering.
• Do Not Miss Diagnoses
  • Subarachnoid hemorrhage: Although the blood pressure is normal, a sudden, severe headache (often described as "the worst headache of my life") could indicate a subarachnoid hemorrhage, which is a medical emergency. The absence of elevated blood pressure does not rule out this condition.
  • Meningitis: Inflammation of the protective membranes covering the brain and spinal cord can cause severe headache, fever, and stiff neck. Early diagnosis is crucial for effective treatment.
  • Temporal arteritis: This condition, also known as giant cell arteritis, can cause severe headache, usually in older adults, and is associated with jaw claudication and visual disturbances. It requires prompt treatment to prevent complications like blindness.
• Rare Diagnoses
  • Idiopathic intracranial hypertension (IIH): Characterized by increased intracranial pressure without a detectable cause, often presenting with headache and visual disturbances. It's more common in obese women of childbearing age.
  • Trigeminal neuralgia: A chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. The pain of trigeminal neuralgia is often described as sharp, stabbing, or like an electric shock.
  • Hypnic headache: A rare headache disorder that occurs only during sleep and wakes the patient, typically in the middle-aged or elderly population.