Migraine differential diagnosis: Difference between revisions

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{| class="wikitable"
{| class="wikitable"
! rowspan="2" |Disease
! rowspan="3" |Disease
! rowspan="2" |Symptoms
! colspan="3" |Symptoms
! colspan="2" |Diagnosis
! rowspan="3" |Gold Standard
! rowspan="3" |CT/MRI
! rowspan="3" |Other Investigation Findings
|-
|-
!CT/MRI
! colspan="2" |'''Headache'''
!Other Investigation Findings
! rowspan="2" |Other features
|-
|-
|[[Migraine]]
!Onset
|
!Characterstics
* Severe or moderate [[headache]] (which is often one-sided and pulsating) lasts between several hours to three days.
* Other [[symptoms]] include gastrointestinal upsets, such as [[nausea and vomiting]], and a heightened sensitivity to bright lights ([[photophobia]]) and noise ([[phonophobia]]). Approximately one third of people who experience [[migraine]] get a preceding [[Aura (symptom)|aura]].<sup>[[Migraine overview#cite note-4|[4]]]</sup> 
|
* [[CT]] and [[MRI]] may be needed to rule out other suspected possible causes of [[headache]].
 
|[[Migraine]] is a clinical [[diagnosis]] that does not require any laboratory tests. Laboratory tests can be ordered to rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of [[migraine]] therapy.
|-
|-
|[[Subarachnoid hemorrhage]]  
|[[Subarachnoid hemorrhage]]  
|Sudden
|
* [[Headache|Severe headache]]
* <nowiki/>[[Thunderclap headache|Thunderclap]]
* Described as the worst headache of life
|
|
* [[Headache|Severe headache]] (as a worst headache of the life)
* Headache is the main symptom (often starts suddenly and starts after a popping or snapping feeling in the head)
* [[Double vision]]
* [[Double vision]]
* [[Nausea]] and [[vomiting]]
* [[Nausea]] and [[vomiting]]
* Symptoms of [[meningeal irritation]]
* Symptoms of [[meningeal irritation]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
* Rapid progression of symptoms
|[[Digital subtraction angiography]]
|
|
* The modality of choice for diagnosis of [[subarachnoid hemorrhage]] is noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* The modality of choice for diagnosis of [[subarachnoid hemorrhage]] is noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
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|-
|-
|[[Meningitis]]
|[[Meningitis]]
|
|Sudden
* [[Headache]]  
|[[Headache]] is associated with:
* [[Neck stiffness]]
* [[Fever]]  
* [[Fever]]  


* [[Photophobia]] (inability to tolerate bright light)
* [[Neck stiffness]]
* [[Phonophobia]] (inability to tolerate loud noises) 
|
* [[Irritability]], [[altered mental status]] (in small children)
* [[Photophobia]]   
* [[Phonophobia]] 
* [[Irritability]]
* [[Altered mental status]]
|[[Lumbar puncture]] for [[CSF]]
|
|
* [[CT]] scan of the head may be performed before [[Lumbar puncture|LP]] to determine the risk of [[herniation]].
* [[CT]] scan of the head may be performed before [[Lumbar puncture|LP]] to determine the risk of [[herniation]].
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|-
|-
|[[Intracranial mass]]
|[[Intracranial mass]]
|Gradual
|[[Morning headache]]
|
|
* [[Headache]]
* [[Nausea]]
* [[Nausea]]
* [[Vomiting]]
* [[Vomiting]]
* [[Change in mental status]]
* [[Change in mental status]]
* [[Seizures]]
* [[Seizures]]
* Focal symptoms of brain damage
* Focal neurological deficits
* Associated co-morbid conditions like [[tuberculosis]], etc
|[[MRI]]
|
|
* [[CT]] or [[MRI]] is the initial test to detect intracranial lesions.  
* [[CT]] or [[MRI]] is the initial test to detect intracranial lesions (ring enhancing lesions).  
* These imaging tests determine the location of [[intracranial mass]] lesion(s) and help in guiding [[therapy]].
* These imaging tests determine the location of [[intracranial mass]] lesion(s) and help in guiding [[therapy]].
|
|
* [[Biopsy]] of the lesion is needed to identify the nature of the lesion such as:
* [[Biopsy]] of the lesion may be done to identify the nature of the lesion such as:
** [[Tumor]]  
** [[Tumor]]  
** [[Abscess]]
** [[Abscess]]
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|-
|-
|[[Cerebral hemorrhage]]
|[[Cerebral hemorrhage]]
|Sudden
|Rapidly progressing headache
|
|
* [[Headache]], vomiting, and depressed level of [[consciousness]] from [[increased intracranial pressure]] (ICP)  
* Symptoms of [[increased intracranial pressure]] (ICP)


* Progression of focal neurological deficits over periods of hours
* Focal neurological deficits
|[[CT]] without [[Contrast medium|contrast]]
(differentiate [[ischemic stroke]] from [[hemorrhagic stroke|hemorrhagic stroke.]])
|
|
* [[CT scan]] without contrast is the initial test performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]]
* [[CT]] is very sensitive for identifying acute [[hemorrhage]] which appears as hyperattenuating clot.
* [[CT]] is very sensitive for identifying acute [[hemorrhage]] which appears as hyperattenuating clot.
* Gradient echo and T2 susceptibility-weighted [[MRI]] are as sensitive as [[CT]] for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.
* Gradient echo and T2 susceptibility-weighted [[MRI]] are as sensitive as [[CT]] for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.
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|-
|-
|[[Cerebral]] [[Infarction]]
|[[Intracranial venous thrombosis]]
|The [[symptoms]] of an [[ischemic stroke]] vary widely depending on the site and blood supply of the area involved. For more information on [[symptoms]] of [[ischemic stroke]] based on area involved please [[Ischemic stroke#Diagnosis#History and symptoms|click here]].
|Gradual
|
|
* [[CT scan]] without contrast is the initial test performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]] CT may show hypo-attenuation and swelling of involved area.
* Diffuse [[headache]]  
* [[MRI|MR]] diffusion weighted imaging is the most sensitive and specific test for diagnosing [[ischemic stroke]] and may help detect presence of [[infarction]] in few minutes of onset of [[symptoms]].
|
* [[Carotid]] [[doppler]] may be done to check for patency of [[carotid arteries]] and blood supply to the [[brain]].


* Cerebral [[angiogram]] is an [[Invasive (medical)|invasive]] test and detect [[abnormalities]] of the [[blood vessels]], including narrowing, blockage, or [[malformations]] (such as [[Aneurysm|aneurysms]] or [[arterio-venous malformations]]). 
* [[Headache]] can be the only symptom of [[Cerebral venous sinus thrombosis|cerebral venous thrombosis]]
 
|-
|[[Intracranial venous thrombosis]]
|
|
* [[Headache]]: It is a common presentation (present in 90% of cases); it tends to worsen over a period of several days, but may also develop suddenly ([[thunderclap headache]]).<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-Stam2005-1|[1]]]</sup> The [[headache]] may be the only [[symptom]] of [[cerebral venous sinus thrombosis]].<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-Cumurciuc2005-2|[2]]]</sup>
* Focal neurological deficits
* Inability to move one or more limbs.
* [[Seizure|Seizures]]  
* Weakness on one side of the face.
* [[Coma|Depressed level of consciousness]] 
* [[Seizure|Seizures]]: 40% of all patients have seizure.
|[[Digital subtraction angiography]]
* [[Coma|Depressed level of consciousness]] and otherwise unexplained changes in [[mental status]] are common symptoms in the elderly.<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-4|[4]]]</sup>
|
|
* The classic finding of sinus thrombosis on unenhanced [[CT]] images is a hyperattenuating thrombus in the occluded sinus.
* The classic finding of sinus thrombosis on unenhanced [[CT]] images is a hyperattenuating thrombus in the occluded sinus.
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* [[Cerebral angiography]] may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
* [[Cerebral angiography]] may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
|-
|[[Migraine]]
|Sudden
|
* Severe to moderate [[headache]]
* One-sided
* Pulsating
* Lasts between several hours to three days.
|
* [[Nausea and vomiting]]
* Preceding [[Aura (symptom)|aura]]
* [[Photophobia]]
* [[Phonophobia]]
|'''---'''
|
* [[CT]] and [[MRI]] may be needed to rule out other suspected possible causes of [[headache]].
|[[Migraine]] is a clinical [[diagnosis]] that does not require any laboratory tests. Laboratory tests can be ordered to rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of [[migraine]] therapy.
|-
|-
|[[Head injury]]
|[[Head injury]]
|Sudden
|
* Dull
* Throbbing
* One sided or all around
|
|
* [[Headache]]
* [[Confusion]]
* [[Confusion]]
* [[Drowsiness]]
* [[Drowsiness]]
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* [[Nausea]] and [[vomiting]]
* [[Nausea]] and [[vomiting]]
* [[Headache|Loss of consciousness]]
* [[Headache|Loss of consciousness]]
* [[lucid interval]]
* [[Lucid interval]]
|[[CT]] scan without contrast
|
|
* [[CT]] scan is the first test performed and identifies [[cerebral hemorrhage]] (appears as hyperattenuating clot) following head injury. [[CT]] scan is also less time consuming.
* [[CT]] scan is the first test performed and identifies [[cerebral hemorrhage]] (appears as hyperattenuating clot) following head injury.  


* [[MRI]] is more sensitive, takes more time and is done in patients with symptoms unexplained by [[Computed tomography|CT]] scan.  
* [[MRI]] is more sensitive, takes more time and is done in patients with symptoms unexplained by [[Computed tomography|CT]] scan.  
|
|
* The [[Glasgow Coma Scale]] is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury.  
* The [[Glasgow Coma Scale]] is a tool for measuring degree of unconsciousness and is a useful tool for determining severity of injury.  
* The [[Pediatric Glasgow Coma Scale]] is used in young children.
* The [[Pediatric Glasgow Coma Scale]] is used in young children.
|-
|-
|[[Lymphocytic hypophysitis]]
|[[Lymphocytic hypophysitis]]
|[[Lymphocytic hypophysitis]] is most often seen in late pregnancy or the [[postpartum]] period with the following symptoms:
|Sudden
|
* Generalized
 
* Retro-orbital or Bitemporal
|
* Most often seen in late pregnancy or the [[postpartum]] period  
 
* Mass lesion effect such as [[Visual field defect|visual field defects]]
* [[Hypopituitarism]]
* [[Hypopituitarism]]
* Mass lesion effect such as [[headache]] or [[Visual field defect|visual field defects]]
|Pituitary biopsy
|
|
* [[CT]] & [[MRI]] typically reveal features of a pituitary mass.
* [[CT]] & [[MRI]] typically reveal features of a pituitary mass.
|
|
* The most accurate test is pituitary [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]].
* The most accurate test is pituitary [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]].
|-
|}
|[[Radiation injury]]
 
|
==References==
* [[Headache]]
{{Reflist|2}}
* Impairment of [[mental function]] is the most prominent feature such as [[Personality change due to another medical condition|personality change]], impairment of memory, [[confusion]], [[learning difficulties]].
 
* Focal [[neurological]] abnormalities and evidence of [[raised intracranial pressure]].
{{reflist|2}}
|
 
[[CT]] & [[MRI]] will show:
[[Category:Needs content]]
* Focal [[radiation]] [[necrosis]]
[[Category:Emergency medicine]]
* Diffuse [[white matter]] injury
[[Category:Endocrinology]]
* Contrast-enhancing mass surrounded by [[edema]] and mass effect
[[Category:Neurology]]
|[[PET scan]]
[[Category:Obstetrics]]
* [[Radiation]] [[necrosis]] is hypo metabolic and will have decreased uptake of [[fluorodeoxyglucose]].
[[Category:Disease]]


|}
{{WH}}


==Other Conditions causing headache==
==Other Conditions causing headache==

Revision as of 18:54, 1 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Other conditions that can cause similar symptoms to a migraine headache include temporal arteritis, cluster headaches, acute glaucoma, meningitis and subarachnoid hemorrhage.[1] Temporal arteritis typically occurs in people over 50 years old and presents with tenderness over the temple, cluster headaches presents with one-sided nose stuffiness, tears and severe pain around the orbits, acute glaucoma is associated with vision problems, meningitis with fevers, and subaracchnoid hemorrhage with a very fast onset.[1] Tension headaches typically occur on both sides, are not pounding, and are less disabling.[1]

Differentiating Migraine From Other Diseases

Migraine should be differentiated from other diseases causing severe headache for example: [2][3][4][5][6][7][8][9][10][11]

Disease Symptoms Gold Standard CT/MRI Other Investigation Findings
Headache Other features
Onset Characterstics
Subarachnoid hemorrhage Sudden Digital subtraction angiography
Meningitis Sudden Headache is associated with: Lumbar puncture for CSF
  • CT scan of the head may be performed before LP to determine the risk of herniation.
  • Diagnosis is based on clinical presentation in combination with CSF analysis.
  • CSF analysis is the investigation of choice.
  • For more information on CSF analysis in meningitis please click here.
Intracranial mass Gradual Morning headache MRI
  • CT or MRI is the initial test to detect intracranial lesions (ring enhancing lesions).
  • These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.
  • Biopsy of the lesion may be done to identify the nature of the lesion such as:
  • X- ray of the skull is a non specific test, but useful if any of the lesions are calcified.
Cerebral hemorrhage Sudden Rapidly progressing headache
  • Focal neurological deficits
 CT without contrast

(differentiate ischemic stroke from hemorrhagic stroke.)

  • CT is very sensitive for identifying acute hemorrhage which appears as hyperattenuating clot.
  • Gradient echo and T2 susceptibility-weighted MRI are as sensitive as CT for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.
Intracranial venous thrombosis Gradual Digital subtraction angiography
  • The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.
  • Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
Migraine Sudden
  • Severe to moderate headache
  • One-sided
  • Pulsating
  • Lasts between several hours to three days.
 ---
  • CT and MRI may be needed to rule out other suspected possible causes of headache.
 Migraine is a clinical diagnosis that does not require any laboratory tests. Laboratory tests can be ordered to rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of migraine therapy.
Head injury Sudden
  • Dull
  • Throbbing
  • One sided or all around
 CT scan without contrast
  • CT scan is the first test performed and identifies cerebral hemorrhage (appears as hyperattenuating clot) following head injury.
  • MRI is more sensitive, takes more time and is done in patients with symptoms unexplained by CT scan.
Lymphocytic hypophysitis Sudden
  • Generalized
  • Retro-orbital or Bitemporal
  • Most often seen in late pregnancy or the postpartum period
 Pituitary biopsy
  • CT & MRI typically reveal features of a pituitary mass.

References

  1. ↑ 1.0 1.1 1.2 Gilmore B, Michael M (2011). "Treatment of acute migraine headache". Am Fam Physician. 83 (3): 271–80. PMID 21302868.
  2. ↑ Endrit Ziu & Fassil Mesfin (2017). "Subarachnoid Hemorrhage". PMID 28722987.
  3. ↑ Benedikt Schwermer, Daniel Eschle & Constantine Bloch-Infanger (2017). "[Fever and Headache after a Vacation in Thailand]". Deutsche medizinische Wochenschrift (1946). 142 (14): 1063–1066. doi:10.1055/s-0043-106282. PMID 28728201.
  4. ↑ Otto Rapalino & Mark E. Mullins (2017). "Intracranial Infectious and Inflammatory Diseases Presenting as Neurosurgical Pathologies". Neurosurgery. doi:10.1093/neuros/nyx201. PMID 28575459.
  5. ↑ I. B. Komarova, V. P. Zykov, L. V. Ushakova, E. K. Nazarova, E. B. Novikova, O. V. Shuleshko & M. G. Samigulina (2017). "[Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]". Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 117 (3. Vyp. 2): 11–19. doi:10.17116/jnevro20171173211-19. PMID 28665364.
  6. ↑ Sanjay Konakondla, Clemens M. Schirmer, Fengwu Li, Xiaogun Geng & Yuchuan Ding (2017). "New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments". Aging and disease. 8 (2): 136–148. doi:10.14336/AD.2016.0915. PMID 28400981.
  7. ↑ Priyanka Yadav, Alec L. Bradley & Jonathan H. Smith (2017). "Recognition of Chronic Migraine by Medicine Trainees: A Cross-Sectional Survey". Headache. doi:10.1111/head.13133. PMID 28653369.
  8. ↑ S. Wulffeld, L. S. Rasmussen, B. Hojlund Bech & J. Steinmetz (2017). "The effect of CT scanners in the trauma room - an observational study". Acta anaesthesiologica Scandinavica. 61 (7): 832–840. doi:10.1111/aas.12927. PMID 28635146.
  9. ↑ Johnston PC, Chew LS, Hamrahian AH, Kennedy L (2015). "Lymphocytic infundibulo-neurohypophysitis: a clinical overview". Endocrine. 50 (3): 531–6. doi:10.1007/s12020-015-0707-6. PMID 26219407.
  10. ↑ Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S (2017). "Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours". Nat Rev Neurol. 13 (1): 52–64. doi:10.1038/nrneurol.2016.185. PMID 27982041.
  11. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.

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Other Conditions causing headache

References

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