What are the differential diagnoses for sharp left-sided cephalic and facial pain with photophobia?

Differential Diagnosis for Sharp Left-Sided Cephalic and Facial Pain with Photophobia

The most likely diagnosis is migraine without aura, given the combination of unilateral sharp pain involving both cephalic and facial regions with photophobia, which is a cardinal migraine symptom. 1

Primary Differential Diagnoses

Migraine (Most Likely)

• Migraine is the leading diagnosis when photophobia accompanies unilateral head and facial pain, as photophobia occurs in the majority of migraine patients and demonstrates the highest specificity for this condition compared to other headache disorders 1
• The International Headache Society criteria require at least 2 of the following: unilateral location, pulsating quality, moderate-to-severe intensity, and aggravation by routine physical activity, plus nausea/vomiting or both photophobia and phonophobia 2, 1
• Sharp pain quality does not exclude migraine, though throbbing is more typical 2, 1
• The presence of photophobia is highly specific for migraine diagnosis 1

Trigeminal Autonomic Cephalalgias (TACs)

Cluster headache must be considered if:

• Pain is severe, strictly unilateral, orbital/supraorbital/temporal in location 1
• Duration is 15-180 minutes (untreated) 2
• Accompanied by ipsilateral autonomic features: lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, or eyelid edema 2
• Attack frequency is 1-8 per day during cluster periods 1
• Notably, 48-80% of cluster headache patients report unilateral photophobia, making this symptom less discriminatory than previously thought 3

SUNCT/SUNA (Short-lasting Unilateral Neuralgiform headache attacks) if:

• Attacks last only seconds to several minutes with up to 200 attacks daily 2
• Sharp, stabbing quality with no refractory period between attacks 2
• Prominent autonomic features (tearing, red eye, rhinorrhea) during attacks 2
• 56% of SUNCT patients report unilateral photophobia 3

Trigeminal Neuralgia

• Characterized by paroxysmal attacks lasting 2 seconds to minutes with sharp, shooting, electric shock-like pain 2
• Most commonly affects second and third trigeminal divisions 2
• Triggered by light touch, washing, cold wind, eating, or brushing teeth 2
• Photophobia is NOT a typical feature, making this less likely in your patient 2

Hemicrania Continua

• Continuous unilateral pain with exacerbations 2
• Responds absolutely to indomethacin (diagnostic feature) 2
• 55% report unilateral photophobia 3
• Less likely given the description of "sharp" rather than continuous pain 2

Critical Red Flags Requiring Immediate Evaluation

Obtain urgent neuroimaging if any of the following are present:

• Sudden onset of headache (thunderclap) 4, 5
• Loss of consciousness 4, 5
• Persistent neurological deficits 4, 5
• First headache after age 50 2, 4, 5
• Symptoms lasting >60 minutes without progression to headache 4

Secondary Causes to Exclude

Giant Cell Arteritis (if patient >50 years)

• Temporal region pain with jaw claudication 2
• Scalp tenderness, visual symptoms, fever, myalgia 2
• Requires immediate ESR/CRP and temporal artery evaluation 2
• Critical pitfall: Can mimic temporomandibular disorder in older patients 2

Acute Angle-Closure Glaucoma

• Severe unilateral eye and facial pain 2
• Photophobia with decreased vision, red eye, fixed mid-dilated pupil 2
• Requires immediate ophthalmologic evaluation 2

Meningitis/Subarachnoid Hemorrhage

• Photophobia is a prominent feature in both conditions 6
• Associated with fever, neck stiffness, altered mental status (meningitis) or sudden severe headache (SAH) 2

Diagnostic Approach

Key historical features to elicit:

• Duration: Migraine lasts 4-72 hours; cluster 15-180 minutes; SUNCT seconds to minutes; trigeminal neuralgia seconds to minutes 2
• Frequency: Migraine typically <15 days/month (episodic); cluster 1-8 attacks/day; SUNCT up to 200/day 2
• Autonomic features: Presence strongly suggests TACs over migraine, though overlap exists 2, 3
• Triggers: Light touch suggests trigeminal neuralgia; alcohol/nitroglycerin suggests cluster; stress/hormones/foods suggest migraine 2
• Quality: Electric shock-like favors trigeminal neuralgia; throbbing favors migraine; stabbing favors TACs 2

Physical examination must include:

• Neurologic examination to identify deficits 2
• Palpation of temporal arteries (if >50 years) 2
• Examination for autonomic signs during attack 2
• Trigger point testing (light touch to face for trigeminal neuralgia) 2

Common Diagnostic Pitfalls

• Assuming photophobia excludes TACs: 48-80% of cluster patients and 55-67% of other TAC patients report unilateral photophobia 3
• Missing atypical migraine presentations: Sharp pain quality occurs in migraine variants 1
• Overlooking giant cell arteritis in patients >50: This is a medical emergency requiring immediate corticosteroids 2
• Failing to count attack frequency systematically: Essential for distinguishing between diagnoses 4
• Not recognizing medication overuse headache: Defined as triptan use ≥10 days/month or NSAIDs ≥15 days/month for ≥3 months 5

Recommended Initial Management Pending Definitive Diagnosis

If migraine is most likely:

• Combination therapy with triptan plus NSAID (e.g., naproxen 500-825 mg) at headache onset provides the most effective acute treatment 1, 5
• Limit acute medication to ≤2 days per week to prevent medication overuse headache 1
• Consider preventive therapy if attacks occur ≥2 times per month 1

If cluster headache is suspected:

• High-flow oxygen 12-15 liters/minute via non-rebreather mask for 15-20 minutes is first-line treatment, providing relief in 70-80% within 15 minutes 1

If diagnosis remains uncertain:

• Refer to neurology for definitive diagnosis and management 1
• Consider MRI to exclude structural causes, especially if atypical features present 2