What is the diagnosis for a patient presenting with intermittent peri-orbital (around the eye) paresthesia (abnormal sensation) and numbness on the right side, descending to the jaw and occasionally ascending to the forehead, accompanied by blurred vision in the right eye, exacerbated by fatigue, stress, and computer work, with a history of migraines (approximately 2 episodes per month) relieved by Advil (ibuprofen), and occasional vertical diplopia (double vision) in the evening with fatigue?

Differential Diagnosis

• Single most likely diagnosis
  • Tension-type headache: The patient's symptoms of intermittent headaches that worsen with fatigue and stress, and are accompanied by peri-orbital numbness and paresthesia, are consistent with tension-type headaches. The fact that the headaches are relieved by Advil also supports this diagnosis.
• Other Likely diagnoses
  • Migraine with aura: The patient's history of migraines, and the presence of visual symptoms such as blurred vision and occasional diplopia, suggest that migraine with aura could be a contributing factor to their symptoms.
  • Dry eye syndrome: The patient's symptoms of blurred vision and peri-orbital numbness could be related to dry eye syndrome, particularly given the worsening of symptoms with computer work.
  • Temporomandibular joint (TMJ) disorder: The patient's symptoms of jaw and facial pain, as well as the worsening of symptoms with fatigue and stress, could be consistent with TMJ disorder.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Giant cell arteritis: Although the patient is not reporting any systemic symptoms such as fever or weight loss, giant cell arteritis is a potentially deadly condition that can cause visual symptoms and headaches, and should be considered in the differential diagnosis.
  • Multiple sclerosis: The patient's symptoms of numbness and paresthesia, as well as the presence of vertigo, could be consistent with multiple sclerosis, and this diagnosis should be considered to avoid missing a potentially serious condition.
  • Stroke or transient ischemic attack (TIA): Although the patient is not reporting any other neurologic symptoms, the presence of sudden onset of symptoms such as diplopia and vertigo could be consistent with a stroke or TIA, and this diagnosis should be considered to avoid missing a potentially life-threatening condition.
• Rare diagnoses
  • Trigeminal neuralgia: The patient's symptoms of peri-orbital numbness and paresthesia could be consistent with trigeminal neuralgia, although this condition is relatively rare.
  • Occipital neuralgia: The patient's symptoms of headaches and numbness in the occipital region could be consistent with occipital neuralgia, although this condition is relatively rare.
  • Neuronitis vestibularis: The patient's history of vestibular neuronitis could be contributing to their symptoms of vertigo and imbalance, although this condition is relatively rare.