Differential Diagnosis

• Single most likely diagnosis
  • Migraine: The patient's symptoms of pain radiating to the forehead, associated nausea, and sensitivity to sound are classic for migraine. The relief with Excedrin Migraine, which contains a combination of acetaminophen, aspirin, and caffeine, further supports this diagnosis. The frequency and pattern of the headaches, as well as the improvement with massage for neck and shoulder tightness, also fit with migraine, especially given the potential for bruxism and sleep issues to act as migraine triggers.
• Other Likely diagnoses
  • Tension-type headache: Given the patient's history of bruxism and neck and shoulder tightness, tension-type headache is a plausible diagnosis. These headaches are often described as a band or a squeezing sensation around the forehead, usually bilateral, and can be exacerbated by stress and muscle tension. The improvement with massage supports this diagnosis.
  • Cervicogenic headache: The pain originating in the posterior neck and radiating to the forehead could suggest a cervicogenic headache, which is referred pain from the cervical spine. The relief with massage and the presence of neck and shoulder tightness support this possibility.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Subarachnoid hemorrhage: Although the patient's symptoms do not strongly suggest a subarachnoid hemorrhage (e.g., sudden onset, "thunderclap" headache), any new or changing headache pattern warrants consideration of this diagnosis due to its high morbidity and mortality.
  • Temporal arteritis: This condition, characterized by inflammation of the blood vessels, can cause headaches, but it typically presents in individuals over the age of 50 and is associated with other symptoms like jaw claudication and visual disturbances.
  • Brain tumor: A brain tumor could cause headaches, often worse in the morning and associated with nausea and vomiting. However, other neurological symptoms such as focal deficits, seizures, or changes in mental status are typically present.
• Rare diagnoses
  • Occipital neuralgia: This condition involves inflammation of the occipital nerves and can cause sharp, stabbing pain in the neck and scalp. It could be considered given the posterior neck pain, but it's less likely given the radiating pattern to the forehead and the absence of other specific symptoms like trigger points.
  • Hypnic headache: These are rare headaches that occur only during sleep and wake the patient, typically occurring in older adults. While the patient reports headaches upon waking, the other characteristics don't fully align with hypnic headaches, such as the lack of description of the headache being exclusively sleep-related.