Differential Diagnosis for Migraine in Pregnancy

When considering a differential diagnosis for migraine in pregnancy, it's crucial to approach the diagnosis systematically to ensure that all potential causes are considered. The following categories help in organizing the thought process:

• Single Most Likely Diagnosis

  • Migraine: This is the most likely diagnosis given the presentation of migraine-like symptoms. Migraines are common in women of childbearing age and can continue or even start during pregnancy. The symptoms typically include severe headache, often unilateral, accompanied by nausea, vomiting, and sometimes aura.

• Other Likely Diagnoses

  • Tension headache: These are common and can be exacerbated by the stress of pregnancy. They typically present as a band-like pressure around the head.
  • Sinus headache: Sinus infections can cause headaches that might mimic migraines, especially if they involve the frontal or maxillary sinuses.
  • Cluster headache: Although less common, cluster headaches can occur during pregnancy and are characterized by severe, unilateral orbital or periorbital pain.
  • Pseudotumor cerebri (Idiopathic Intracranial Hypertension): This condition can cause headache that worsens with maneuvers that increase intrathoracic pressure, such as coughing. It's more common in obese women and can be associated with pregnancy.

• Do Not Miss Diagnoses

  • Preeclampsia: A condition characterized by high blood pressure and often protein in the urine, occurring after the 20th week of pregnancy. It can cause severe headaches and is a medical emergency.
  • Stroke or Transient Ischemic Attack (TIA): Although rare, stroke can occur during pregnancy and postpartum. A new-onset, severe headache could be a symptom of a hemorrhagic stroke.
  • Subarachnoid hemorrhage: Often due to aneurysm rupture, this condition presents with a sudden, severe headache (often described as "the worst headache of my life") and can be life-threatening.
  • Venous sinus thrombosis: A rare condition that can cause headache, often accompanied by other neurological symptoms, and requires immediate medical attention.
  • Posterior reversible encephalopathy syndrome (PRES): A condition associated with preeclampsia, eclampsia, and other conditions, characterized by headache, seizures, and visual disturbances.

• Rare Diagnoses

  • Pituitary apoplexy: A rare condition where there is sudden hemorrhage or infarction of the pituitary gland, which can cause a severe headache.
  • Arteriovenous malformation (AVM) or arteriovenous fistula (AVF): These vascular abnormalities can cause headaches and other neurological symptoms, and their rupture can lead to severe consequences.
  • Idiopathic thunderclap headache: A very severe headache that reaches its maximum intensity within a minute, often described as "the worst headache of my life," without an identifiable cause.

Each of these diagnoses requires careful consideration of the patient's symptoms, medical history, and physical examination findings, along with appropriate diagnostic testing to ensure accurate diagnosis and management.