What is the differential diagnosis for daily evening headaches with photosensitivity and phonophobia?

Differential Diagnosis for Daily Evening Headaches with Photosensitivity and Phonophobia

The most likely diagnosis is chronic migraine or chronic daily headache with migraine features, given the presence of photophobia and phonophobia occurring daily—these cardinal migraine symptoms strongly suggest a primary headache disorder rather than secondary pathology. 1

Primary Headache Disorders to Consider

Chronic Migraine (Most Likely)

• Photophobia and phonophobia are cardinal migraine symptoms that occur in the majority of migraine patients and are highly specific for this diagnosis. 1
• Chronic migraine is defined as headaches occurring ≥15 days per month for >3 months, with migraine features on ≥8 days per month. 1
• The evening timing pattern is consistent with migraine, which can have circadian variation. 1
• Daily occurrence with these specific accompanying symptoms (photophobia and phonophobia) makes chronic migraine the primary consideration. 1

Medication-Overuse Headache (Critical to Exclude)

• MOH is a secondary headache disorder that commonly develops from overuse of acute migraine medications and frequently coexists with chronic migraine. 1
• This diagnosis must be actively investigated by obtaining a detailed medication history, including frequency of analgesic, triptan, or combination medication use. 1
• MOH can present with migraine-like features including photophobia and phonophobia. 1

Tension-Type Headache (Less Likely)

• TTH typically lacks the accompanying symptoms of photophobia and phonophobia that characterize migraine. 1
• TTH usually presents with bilateral, mild-to-moderate pressing or tightening pain not aggravated by routine physical activity. 1
• The presence of both photophobia AND phonophobia makes TTH unlikely as the primary diagnosis. 1

New Daily Persistent Headache

• NDPH presents with daily headache from onset, but only 14% of NDPH patients report unilateral photophobia or phonophobia. 2
• This diagnosis should be considered if there is a clear memory of headache onset and daily persistence from that point. 2

Secondary Headache Disorders (Red Flags to Exclude)

Critical red flags requiring immediate investigation include: 1

• Thunderclap headache (sudden, severe onset)
• Atypical aura symptoms
• Recent head trauma
• Unexplained fever
• Impaired memory or cognitive changes
• Focal neurological symptoms that don't resolve
• Progressive worsening pattern

If any red flags are present, neuroimaging (MRI preferred), blood work, or lumbar puncture may be indicated to exclude: 1

• Meningitis
• Subarachnoid hemorrhage
• Intracranial mass lesions
• Idiopathic intracranial hypertension

Diagnostic Approach

Essential History Elements

Document the following specific details: 1

• Age at onset and duration of current daily pattern
• Exact headache frequency (days per month with headache)
• Pain characteristics: location (unilateral vs bilateral), quality (throbbing vs pressing), severity, aggravating factors
• Accompanying symptoms: presence and timing of photophobia, phonophobia, nausea, vomiting
• Aura symptoms: visual phenomena, sensory changes, speech difficulties
• Medication use: type, frequency, and quantity of all acute headache medications

Validated Screening Tools

• The ID-Migraine questionnaire has 81% sensitivity and 93% positive predictive value for migraine diagnosis, asking about nausea, photophobia, and disability. 1
• The Migraine Screen Questionnaire (MS-Q) has 93% sensitivity and includes questions about photophobia and phonophobia specifically. 1

Headache Diary Implementation

• Implement a daily headache diary recording headache frequency, intensity, duration, accompanying symptoms (photophobia, phonophobia, nausea), and all medication use. 1
• This serves both diagnostic and monitoring purposes, particularly to identify medication overuse patterns. 1

Clinical Reasoning

The combination of daily headaches with both photophobia AND phonophobia is highly suggestive of chronic migraine rather than other primary headache disorders. 1 Research shows that 64.9% of migraine patients report all three cardinal symptoms (nausea, photophobia, phonophobia), with photophobia being the most bothersome symptom in 49.1% of cases. 3

Important distinction: While unilateral photophobia or phonophobia occurs more frequently in trigeminal autonomic cephalalgias (TACs) like cluster headache (48-80% of cases), these conditions typically present with severe unilateral pain, shorter attack duration (15-180 minutes), and ipsilateral cranial autonomic symptoms (conjunctival injection, lacrimation, nasal congestion). 1, 2 The daily evening pattern without these autonomic features makes TACs unlikely.

Common Pitfalls to Avoid

• Do not dismiss the diagnosis of chronic migraine simply because headaches occur daily—chronic migraine by definition occurs ≥15 days per month. 1
• Do not overlook medication overuse—actively quantify all acute medication use, as MOH frequently complicates chronic migraine. 1
• Do not order neuroimaging routinely—imaging is only indicated when red flags suggest secondary headache disorders, and unnecessary imaging can be harmful through radiation exposure. 1
• Do not confuse bilateral photophobia/phonophobia (typical in migraine) with unilateral symptoms (more common in TACs)—the laterality matters for differential diagnosis. 1, 2