Differential Diagnosis for 67-year-old Patient with Headaches and Associated Symptoms
Single Most Likely Diagnosis
- Tension Headache: The patient's description of band-like headaches, exacerbation by movement, and partial relief with acetaminophen are consistent with tension headaches. The fact that the patient denies radiation of pain and has found some relief with over-the-counter medication further supports this diagnosis.
Other Likely Diagnoses
- Cervicogenic Headache: Given the worsening of headaches with movement and bending over, a cervicogenic cause is plausible. This type of headache is referred from the cervical spine and can be exacerbated by specific movements.
- Migraine: Although the patient denies radiation of pain, some migraines can present without aura or with minimal neurological symptoms. The significant pain level (5-10/10) and exacerbation by certain foods (eggs) could suggest a migraine, though the lack of typical migraine features (e.g., photophobia, phonophobia) makes it less likely.
- Anxiety-Related Headache: The patient's reported anxiety score and the description of chest tightness ("like someone has scared her") and shortness of breath could indicate that anxiety is contributing to or causing the headaches.
Do Not Miss Diagnoses
- Subarachnoid Hemorrhage (SAH): Although the patient's symptoms have been ongoing for weeks, which makes SAH less likely, it is crucial to consider this diagnosis due to its high mortality and morbidity. The sudden onset of a severe headache (even if not described as "thunderclap") warrants consideration of SAH.
- Temporal Arteritis (Giant Cell Arteritis): This condition is a medical emergency that can cause severe headaches, jaw claudication, and visual disturbances. The patient's age and the severity of the headaches make this a "do not miss" diagnosis, despite the absence of specific symptoms like jaw pain or visual changes.
- Brain Tumor: A brain tumor could cause headaches that worsen with movement or certain activities due to increased intracranial pressure. Although less likely, given the absence of focal neurological deficits or a history of cancer, it remains a critical diagnosis not to overlook.
Rare Diagnoses
- Idiopathic Intracranial Hypertension (IIH): This condition can cause headaches that are worse in the morning and with certain activities. It is often associated with obesity and can lead to visual disturbances, but the patient's presentation does not strongly suggest IIH.
- Trigeminal Neuralgia: Although typically characterized by sharp, stabbing pains in the face rather than a band-like headache, it's a rare condition that could be considered if the patient's symptoms were more localized to the face or had specific triggers.
History of Present Illness (HPI)
The patient is a 67-year-old woman who presents with a 1-2 week history of severe, band-like headaches rated 5-10/10 on the pain scale. These headaches are exacerbated by movement and after eating eggs. She experiences partial relief with acetaminophen but denies any radiation of pain. Additionally, she reports feeling anxious, with a notable anxiety score, and describes chest tightness and shortness of breath that have been ongoing for about a week. She has stopped eating eggs, believing her symptoms might be related to a cholesterol issue. The headaches worsen when she bends over, and she has refused both medication for anxiety and a toradol injection for pain management, expressing a desire only for her labs to be checked.