What are the differential diagnoses for a 50-year-old man presenting with a migraine-like headache?

Differential Diagnoses for Migraine-Like Headache in a 50-Year-Old Male

In a 50-year-old man presenting with migraine-like headache, the most critical differentials are giant cell arteritis, subarachnoid hemorrhage, brain tumor, and stroke—because new-onset headache after age 50 is a red flag that mandates urgent evaluation for secondary causes, which are 12 times more likely in this age group than in younger adults. 1, 2

Primary Headache Differentials

Tension-Type Headache

• Bilateral, pressing/tightening quality of mild-to-moderate intensity, not aggravated by routine physical activity 3, 1
• Lacks nausea/vomiting and the combination of photophobia plus phonophobia that characterizes migraine 3, 1
• Duration highly variable (30 minutes to 7 days), often shorter than migraine's 4-72 hour window 1

Cluster Headache

• Strictly unilateral severe headache lasting 15-180 minutes, occurring 1-8 times daily 3, 1, 4
• Ipsilateral autonomic symptoms are pathognomonic: lacrimation, conjunctival injection, nasal congestion, ptosis, miosis, eyelid edema 3, 1, 4
• Prevalence only 0.1% of population, but critical not to miss 3, 4
• Absence of nausea/vomiting and photophobia-phonophobia combination helps distinguish from migraine 1

Chronic Migraine

• ≥15 headache days per month for >3 months, with ≥8 days meeting migraine criteria 1, 4
• Represents progression from episodic migraine and requires different management approach 1

Medication-Overuse Headache (MOH)

• ≥15 headache days per month with regular overuse of non-opioid analgesics ≥15 days/month OR other acute medications ≥10 days/month for >3 months 3, 1, 4
• Often develops from excessive treatment of migraine attacks, creating a vicious cycle 3
• Many patients don't consider over-the-counter analgesics as "real" medications, leading to under-recognition 1

Life-Threatening Secondary Headache Differentials

Giant Cell Arteritis (Temporal Arteritis)

• Most critical diagnosis not to miss in this age group 1, 5
• New-onset headache in patient >50 years with scalp tenderness, jaw claudication 1, 4
• ESR can be normal in 10-36% of cases, so clinical suspicion should prompt rheumatology referral regardless of lab results 1, 4, 5
• Headache is the most common symptom, reported by 60-90% of patients 5
• Requires immediate rheumatology referral to prevent irreversible vision loss 1, 4

Subarachnoid Hemorrhage (SAH)

• Thunderclap headache ("worst headache of life") with abrupt onset 3, 1, 4
• May have altered taste sensation 1
• Non-contrast CT within 6 hours has 95% sensitivity, declining to 74% by day 3 and 50% at 1 week 1, 4, 5
• If CT negative, lumbar puncture with spectrophotometry for xanthochromia is 100% sensitive at 12 hours through 2 weeks 5

Brain Tumor or Space-Occupying Lesion

• Progressive headache that awakens patient from sleep 1, 4
• Worsens with Valsalva maneuver, coughing, or exertion 1, 4
• New-onset headache after age 50 increases suspicion 1, 4, 6
• MRI with and without contrast is preferred imaging modality for subacute presentations 1, 7, 4

Stroke or Transient Ischemic Attack (TIA)

• Atypical aura with focal neurological symptoms lasting >60 minutes 1
• Any focal neurological signs or symptoms warrant urgent evaluation 1, 6

Meningitis

• Headache with neck stiffness and unexplained fever 3, 1
• Requires immediate evaluation as life-threatening condition 1

Increased Intracranial Pressure

• Headache worsening with coughing, sneezing, exercise 1
• May awaken patient from sleep 1

Spontaneous Intracranial Hypotension

• Orthostatic headache: absent/mild on waking, onset within 2 hours of upright posture, >50% improvement within 2 hours of lying flat 1
• Requires urgent neurology referral within 48 hours 1, 4

Critical Red Flags Requiring Urgent Investigation

Any of the following mandate immediate neuroimaging or emergency referral: 3, 1, 4, 6

• Thunderclap headache (abrupt onset, maximal intensity within seconds)
• New-onset headache after age 50 (12-fold increased risk of serious pathology) 2
• Progressive worsening over weeks to months
• Headache awakening patient from sleep
• Atypical aura (focal neurological symptoms, duration >60 minutes)
• Recent head or neck trauma
• Headache brought on by Valsalva, cough, or exertion
• Focal neurological symptoms or signs on examination
• Unexplained fever
• Neck stiffness or limited neck flexion
• Altered consciousness, memory, or personality
• Witnessed loss of consciousness
• Papilledema on fundoscopic examination

Diagnostic Approach

History Taking

• Document exact age of onset—migraine typically begins at/around puberty, so new onset at 50 is atypical 1
• Duration of episodes: migraine 4-72 hours; cluster 15-180 minutes; tension-type variable 1
• Pain location: unilateral (migraine, cluster) vs bilateral (tension-type) 1
• Pain quality: pulsating (migraine) vs pressing/tightening (tension-type) vs severe unilateral (cluster) 1
• Aggravating factors: routine activity worsens migraine but not tension-type 1
• Accompanying symptoms: nausea/vomiting, photophobia, phonophobia (migraine); autonomic symptoms (cluster) 1
• Medication history: both prescription and over-the-counter use to assess for MOH 1

Physical Examination

• Thorough neurological examination is mandatory—any abnormal finding significantly increases probability of secondary pathology 1, 6
• Check for scalp tenderness (giant cell arteritis) 1
• Assess for neck stiffness (meningitis, SAH) 1
• Fundoscopic examination for papilledema (increased intracranial pressure) 6

Neuroimaging Indications

In a 50-year-old with new-onset headache, neuroimaging is strongly recommended even with normal examination, given the age-related increased risk of secondary causes. 1, 7, 2

• MRI with and without contrast is preferred for subacute presentations or suspected tumor/inflammatory process 1, 7, 4
• Non-contrast CT only if presenting <6 hours from acute severe headache onset (to rule out SAH) 1, 4
• Neuroimaging in typical migraine with normal exam has only 0.2% yield in younger patients, but this does not apply to new-onset headache after age 50 1, 4

Laboratory Testing

• ESR and CRP if giant cell arteritis suspected, though normal in 10-36% of cases 1, 4, 5
• Morning TSH and free T4 if cold intolerance or lightheadedness present 1, 7

Screening Tools

• ID-Migraine questionnaire (3-item): sensitivity 0.81, specificity 0.75 1, 7
• Migraine Screen Questionnaire (5-item): sensitivity 0.93, specificity 0.81 1, 7
• Headache diary to document frequency, duration, characteristics, triggers 1, 7

Common Pitfalls

• Dismissing new-onset headaches in patients >50 as "just migraine"—this age group has substantially higher risk of secondary causes requiring urgent treatment 1, 2
• Relying solely on ESR to rule out giant cell arteritis—up to 36% can have normal ESR 1, 4, 5
• Missing medication-overuse headache because patients don't report over-the-counter analgesics 1
• Ordering routine neuroimaging for typical migraine in younger patients with normal exam—but this caution does NOT apply to new-onset headache after age 50 1, 4

Referral Thresholds

• Emergency admission: any red-flag feature present 1, 4
• Urgent neurology referral (within 48 hours): suspected spontaneous intracranial hypotension 1, 4
• Routine neurology referral (2-4 weeks): diagnosis uncertain, first-line treatments fail 1, 4
• Rheumatology referral: suspected giant cell arteritis 1, 4