Migraine Diagnosis Differential

When considering a diagnosis of migraine, it's crucial to differentiate it from other conditions that may present with similar symptoms. The following differential diagnosis is organized into categories to help guide the diagnostic process:

• Single Most Likely Diagnosis

  • Migraine: This is the most likely diagnosis given the presentation of recurrent, severe headaches often accompanied by sensitivity to light, sound, or nausea. The diagnosis is typically made based on clinical criteria, including the frequency, duration, and characteristics of the headaches, as well as the presence of aura symptoms in some cases.

• Other Likely Diagnoses

  • Tension-Type Headache: Often presents with a band-like pressure around the head, which is typically less severe than migraine but can be confused with migraine due to overlapping symptoms.
  • Cluster Headache: Characterized by severe, unilateral orbital or periorbital pain, often accompanied by autonomic symptoms like lacrimation or nasal congestion. While distinct, the severity and unilateral nature can sometimes be confused with migraine.
  • Sinus Headache: Headaches caused by sinus inflammation can mimic migraine, especially if the pain is facial and accompanied by other sinus symptoms like congestion or fever.

• Do Not Miss Diagnoses

  • Subarachnoid Hemorrhage: A life-threatening condition caused by bleeding into the space surrounding the brain, often presenting with a sudden, severe headache (often described as "the worst headache of my life"). Although less common, missing this diagnosis can be fatal.
  • Temporal Arteritis: An inflammatory condition affecting the blood vessels, particularly in older adults, which can cause headaches, visual disturbances, and jaw claudication. Missing this diagnosis can lead to blindness or stroke.
  • Idiopathic Intracranial Hypertension (IIH): Characterized by increased pressure within the skull without an apparent cause, often presenting with headache and visual symptoms. If untreated, IIH can lead to permanent vision loss.

• Rare Diagnoses

  • Trigeminal Neuralgia: A chronic pain condition that affects the trigeminal nerve, causing intense shock-like or stabbing pain in parts of the face. While rare, it can be mistaken for migraine due to the severe pain.
  • Hypnic Headache: A rare headache disorder that occurs only during sleep and wakes the patient, often described as a dull, bilateral headache. Its unique characteristic of occurring exclusively during sleep distinguishes it from migraine.
  • Hemicrania Continua: A rare, continuous, and strictly unilateral headache that can be accompanied by autonomic symptoms. It is highly responsive to indomethacin, distinguishing it from other headache disorders.

Each of these diagnoses has distinct features that can help differentiate them from migraine. A thorough clinical evaluation, including history, physical examination, and sometimes diagnostic tests, is essential for making an accurate diagnosis.