What is the differential diagnosis and management for an 18-year-old female patient presenting with body ache, severe headache, nausea, dizziness, tinnitus (ringing in the ears), back pain, depression, and anxiety?

Differential Diagnosis and Management for 18-Year-Old with Headache, Body Ache, Nausea, Dizziness, Tinnitus, Back Pain, Depression, and Anxiety

Primary Assessment Priority

This presentation requires immediate evaluation for secondary headache causes before attributing symptoms to primary headache disorders, particularly given the constellation of severe headache, nausea, dizziness, and tinnitus. 1

Red Flag Assessment

Evaluate immediately for dangerous secondary causes by assessing these specific features:

• Sudden onset of "worst headache of life" - if present, suggests subarachnoid hemorrhage requiring emergent head CT without contrast 2
• Focal neurologic deficits - any weakness, sensory changes, or asymmetric findings 1
• Papilledema on fundoscopic exam - indicates increased intracranial pressure 1
• Neck stiffness with fever - suggests meningitis/encephalitis 1
• Personality changes or altered mental status - indicates serious intracranial pathology 1
• Headache worse with exercise or positional changes 1

If any red flags present, obtain head CT without contrast immediately for suspected hemorrhage, or MRI/CT for other dangerous causes 1

Differential Diagnosis

Primary Considerations

Chronic Migraine with Psychiatric Comorbidity (Most Likely)

• Meets criteria if experiencing ≥15 headache days per month for ≥3 months, with headaches lasting ≥4 hours 2, 3
• Associated features: nausea, body ache, dizziness strongly support migraine 2
• Depression and anxiety are highly comorbid with migraine (OR 2.1 for depression, OR 2.4-4.2 for anxiety in females) 4, 5
• Tinnitus can coexist with migraine, though requires specific evaluation 2

Complex Chronic Pain Syndrome

• Body ache, back pain, headache, and psychiatric symptoms suggest fibromyalgia or amplified musculoskeletal pain syndrome (AMPS) 6
• 94% of adolescent chronic headache patients experience multiple pain types beyond headaches 6
• 71% of adolescent headache patients have diagnosed psychiatric disorders 6

Medication Overuse Headache (if applicable)

• Must assess current analgesic use: >15 days/month of simple analgesics or >10 days/month of triptans indicates medication overuse 3
• Strongly associated with depression (OR 5.5) and anxiety (OR 7.1-10.4) 5

Secondary Causes to Exclude

Tinnitus-Related Pathology

• Nonpulsatile tinnitus (continuous ringing) is most common (70-80% subjective) 2
• AAO-HNS guidelines recommend AGAINST imaging for nonpulsatile tinnitus that is bilateral, without focal neurologic deficits, and without asymmetric hearing loss 2
• Requires comprehensive audiological examination if hearing problems or unilateral persistent tinnitus present 2
• Depression and anxiety with tinnitus require prompt identification and intervention per AAO-HNS 2

Intracranial Pathology

• Vestibular schwannoma - if unilateral tinnitus with hearing loss 2
• Vascular malformations - if pulsatile tinnitus present 2
• Space-occupying lesions - if progressive symptoms or focal deficits 1

Initial Diagnostic Workup

History Elements (Specific Details Required)

Headache Characterization:

• Frequency: number of headache days per month (≥15 = chronic) 2, 3
• Duration: hours per episode (≥4 hours supports migraine) 2
• Quality: throbbing/pulsating vs. pressure-type 2
• Severity: rate 0-10, assess disability impact 2
• Associated symptoms: photophobia, phonophobia, aura 2
• Temporal pattern: sudden vs. gradual onset, time of day 2

Medication History:

• Current analgesic use: frequency per month (critical for medication overuse) 3
• Previous preventive trials and responses 6
• Psychiatric medications 6

Tinnitus Characterization:

• Unilateral vs. bilateral 2
• Pulsatile (rhythmic with heartbeat) vs. nonpulsatile (continuous) 2
• Associated hearing loss or asymmetry 2

Psychiatric Assessment:

• Screen for depression and anxiety using validated tools (HADS recommended) 5
• Assess for suicidal ideation (16% of adolescent headache patients have suicide/self-harm history) 6
• Evaluate catastrophizing and functional impairment 6

Physical Examination

Neurologic Examination:

• Cranial nerves (especially II for papilledema, VII-VIII for hearing/balance) 1
• Motor strength symmetry 1
• Sensory examination 1
• Cerebellar testing (coordination, gait) 1
• Neck stiffness assessment 2

Otoscopic Examination:

• Essential for tinnitus evaluation to detect retrotympanic lesions 2
• Assess tympanic membrane mobility 2

Imaging Decisions

Do NOT obtain imaging if:

• Nonpulsatile tinnitus, bilateral, no focal neurologic deficits, no asymmetric hearing loss 2
• Primary headache pattern without red flags 1

Obtain MRI brain if:

• Unilateral persistent tinnitus with hearing problems 2
• Any red flag features present 1
• Focal neurologic abnormalities 2
• Asymmetric hearing loss 2

Obtain audiometry if:

• Any hearing complaints 2
• Unilateral persistent tinnitus 2

Management Algorithm

Step 1: Address Psychiatric Comorbidity First

Depression and anxiety require prompt identification and intervention per AAO-HNS guidelines 2

• Initiate SSRI (e.g., fluoxetine) - has evidence for migraine prophylaxis AND treats depression/anxiety 2
• Consider tricyclic antidepressant (amitriptyline) - evidence-based for both episodic and chronic migraine prophylaxis 2
• Refer to psychiatry/psychology for cognitive behavioral therapy 6
• Screen for catastrophizing and address with behavioral interventions 6

Step 2: Acute Migraine Treatment

For moderate to severe headache episodes:

• First-line: NSAID (e.g., ibuprofen 400-800mg or naproxen 500-1000mg) 2
• If inadequate response to NSAID alone: Add triptan to NSAID (strong recommendation, moderate-certainty evidence) 2
• Alternative: Triptan plus acetaminophen if NSAID contraindicated (conditional recommendation, low-certainty evidence) 2
• Limit simple analgesics to <15 days/month and triptans to <10 days/month to prevent medication overuse headache 3

Step 3: Preventive Treatment (If Chronic Migraine Confirmed)

If ≥15 headache days/month for ≥3 months:

First-line oral preventives (try before injectable therapies):

• Topiramate 25-100mg daily (Level A evidence for chronic migraine) 2, 3
• Amitriptyline 25-100mg nightly (evidence-based, treats comorbid depression/anxiety) 2, 3
• Propranolol 80-240mg daily (if no contraindications like low blood pressure/dizziness) 3

Second-line if oral preventives fail after adequate trial (2-3 months each):

• OnabotulinumtoxinA (Botox) 155-195 units every 12 weeks per PREEMPT protocol - FDA-approved specifically for chronic migraine prophylaxis 3
• Reduces headache days by 1.9-3.1 days/month compared to placebo 3
• Requires failure of 2-3 oral preventives first due to cost considerations 3
• NOT effective for episodic migraine (<15 headache days/month) 3

Step 4: Address Body Ache and Back Pain

If pain persists beyond headache treatment:

• Consider fibromyalgia or AMPS diagnosis (15% each in adolescent headache cohorts) 6
• Requires holistic pain management approach beyond conventional pharmacology 6
• Physical therapy and graded exercise program 6
• Multidisciplinary pain clinic referral if complex chronic pain syndrome suspected 6

Step 5: Tinnitus Management

Conservative approach per AAO-HNS guidelines:

• Reassurance if bilateral nonpulsatile tinnitus without hearing loss 2
• Audiometry if any hearing concerns 2
• Address anxiety/depression as these worsen tinnitus perception 2
• Sound therapy or hearing aids if hearing loss present 2
• No imaging needed if bilateral, nonpulsatile, no focal deficits, no asymmetric hearing loss 2

Follow-Up Strategy

• Document headache frequency, intensity, and quality of life impact at each visit using headache diary 3
• Reassess at 2-3 months after initiating preventive therapy 3
• Screen for medication overuse at every visit 3
• Monitor psychiatric symptoms with validated tools (HADS) 5
• Refer to neurology if: uncertain diagnosis, poor response to preventive strategies, persistent aura, or motor weakness 7
• Refer to pain specialist if complex chronic pain syndrome suspected 6

Common Pitfalls to Avoid

• Failing to screen for depression/anxiety - present in 71% of adolescent headache patients and worsens outcomes 6, 4
• Obtaining unnecessary imaging - not indicated for bilateral nonpulsatile tinnitus without red flags 2
• Missing medication overuse headache - perpetuates chronic migraine and reduces preventive treatment effectiveness 3
• Polypharmacy without systematic approach - adolescent headache patients average 4.5 different medications with poor outcomes 6
• Treating headache in isolation - 94% have multiple pain types requiring comprehensive pain assessment 6
• Premature use of Botox - only indicated after failure of oral preventives and only for chronic (not episodic) migraine 3