Differential Diagnosis for Headache vs Migraine

When attempting to distinguish between a headache and a migraine, it's crucial to consider various diagnoses based on their likelihood and potential impact on the patient's health. The following categorization helps in systematically approaching this differential diagnosis:

• Single Most Likely Diagnosis

  • Migraine: This is often the first consideration for patients presenting with severe, recurrent headaches, especially if accompanied by other migraine-defining features such as aura, photophobia, phonophobia, or nausea. The justification for considering migraine as the single most likely diagnosis lies in its prevalence and the specific constellation of symptoms that differentiate it from other types of headaches.

• Other Likely Diagnoses

  • Tension-Type Headache: This is another common type of headache that, while typically less severe than migraine, can still significantly impact a patient's quality of life. It's characterized by a band-like pressure around the head and is often associated with stress or muscle tension.
  • Cluster Headache: Known for its severe, unilateral pain, cluster headaches occur in cyclical patterns or clusters, and are often accompanied by autonomic symptoms like nasal congestion or eye watering on the affected side.
  • Sinus Headache: Headaches caused by sinusitis or other sinus disorders can mimic migraines but are typically accompanied by other symptoms such as facial pain, nasal congestion, and fever.

• Do Not Miss Diagnoses

  • Subarachnoid Hemorrhage: Although rare, this condition is potentially fatal and presents with a sudden, severe headache often described as "the worst headache of my life." It's crucial to consider this diagnosis in patients with sudden onset of severe headache, especially if accompanied by other symptoms like vomiting, altered consciousness, or focal neurological deficits.
  • Temporal Arteritis: This condition, also known as giant cell arteritis, can cause severe headaches, typically in older adults, and is associated with jaw claudication, visual disturbances, and elevated inflammatory markers. Missing this diagnosis can lead to serious complications, including blindness.
  • Brain Tumor: While rare, headaches can be a presenting symptom of brain tumors, especially if the headache is worsening over time, occurs at night, or is accompanied by other neurological symptoms like seizures, confusion, or focal deficits.

• Rare Diagnoses

  • Trigeminal Neuralgia: Characterized by intense, shock-like or stabbing pain in parts of the face, this condition can sometimes be mistaken for headache or migraine but is much rarer.
  • Occipital Neuralgia: Involves pain in the distribution of the occipital nerves and can be confused with migraine or tension-type headaches but is less common.
  • Hypnic Headache: A rare condition where headaches occur exclusively during sleep, often waking the patient, and can be a diagnostic challenge due to its unique presentation.

Each of these diagnoses requires careful consideration of the patient's symptoms, medical history, and, in some cases, diagnostic testing to accurately differentiate between headache and migraine and to identify other potential causes of headache.