Differential Diagnosis for Migraines

When considering a differential diagnosis for migraines, it's crucial to evaluate a range of potential causes to ensure accurate diagnosis and appropriate treatment. The differential can be categorized as follows:

• Single Most Likely Diagnosis
  • Migraine itself: This is the most straightforward diagnosis when symptoms align with the classic presentation of migraine, including unilateral headache, photophobia, phonophobia, and sometimes aura.
• Other Likely Diagnoses
  • Tension headache: Often presents with bilateral headache and may lack the severe intensity or associated symptoms of migraines.
  • Cluster headache: Known for severe, unilateral orbital or periorbital pain, typically without the visual aura of migraines.
  • Sinus headache: Can mimic migraines but is usually accompanied by sinus pressure, congestion, or facial pain.
  • Medication overuse headache: A consideration in patients with frequent or daily headaches who use acute headache medications regularly.
• Do Not Miss Diagnoses
  • Subarachnoid hemorrhage: A life-threatening condition that can present with a sudden, severe headache (often described as "the worst headache of my life").
  • Meningitis: Inflammation of the protective membranes covering the brain and spinal cord, which can cause headache, fever, and stiff neck.
  • Temporal arteritis: An inflammation of the blood vessels in the head, which can cause headache, visual disturbances, and jaw claudication.
  • Brain tumor: Although rare, can cause headaches that worsen over time, possibly accompanied by focal neurological deficits.
• Rare Diagnoses
  • Trigeminal neuralgia: Characterized by intense pain along a branch of the trigeminal nerve, which can be mistaken for migraine or cluster headache.
  • Occipital neuralgia: Involves pain in the distribution of the occipital nerves and can be confused with migraine or tension headache.
  • Hypnic headache: A rare headache disorder that occurs exclusively during sleep and wakes the patient.
  • New daily persistent headache: A rare condition where a headache begins suddenly and persists daily for more than three months.

Each of these diagnoses has distinct features that can help guide the clinician towards the correct diagnosis. A thorough history, physical examination, and, when necessary, diagnostic tests are essential for distinguishing between these possibilities and ensuring that potentially life-threatening conditions are not overlooked.