Differential Diagnosis for 24-year-old Male with Daily Headaches and Vision Changes

• Single most likely diagnosis:
  • Migraine with aura: The patient's symptoms of daily headaches triggered by light and sound, starting early in the morning and lasting all day, are consistent with migraine. The significant change in vision from 20/20 to 20/200 could be related to migraine aura, which can cause transient visual disturbances. However, the persistent nature of the vision change might suggest other underlying causes.
• Other Likely diagnoses:
  • Hypertension-related headaches: Given the patient's high blood pressure (Stage 1 hypertension with readings up to 158/95), it's possible that the headaches are related to his hypertension. Hypertension can cause headaches, especially in the morning, due to increased intracranial pressure.
  • Tension-type headaches: These are common and could be exacerbated by the patient's high blood pressure and vision changes, leading to increased stress and muscle tension.
  • Glaucoma: The significant decrease in vision could be indicative of glaucoma, especially if it's associated with increased intraocular pressure, which can cause headaches.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):
  • Brain tumor: Although the head CT is negative, it's crucial to consider the possibility of a brain tumor, especially given the significant and rapid decline in vision. Some tumors might not be visible on initial imaging or could be located in areas difficult to assess with standard CT scans.
  • Pituitary apoplexy or tumor: These conditions can cause sudden vision changes and headaches. Given the patient's age and the rapid progression of vision loss, pituitary issues should be considered, especially since they can also affect blood pressure.
  • Arteriovenous malformation (AVM) or other vascular anomalies: These could cause headaches and, if they bleed, could lead to severe consequences. The negative head CT does not entirely rule out these possibilities, especially if the bleed is small or the AVM is not yet symptomatic in a way that would be visible on a CT.
• Rare diagnoses:
  • Idiopathic intracranial hypertension (IIH): This condition, also known as pseudotumor cerebri, can cause increased intracranial pressure without a detectable cause, leading to headaches and vision changes, including blindness if not treated.
  • Optic neuritis: An inflammation of the optic nerve that can cause pain and vision loss, which might be considered given the patient's significant vision change, although it typically presents with pain on eye movement.
  • Malignant hypertension: Although less common, given the patient's age and the presence of significant hypertension, malignant hypertension could be a consideration, especially if there are signs of end-organ damage beyond the vision changes and headaches.