Headache (Cephalgia): Or something else? Differential Diagnosis

Respiratory System (J00-J99)

Eyes and eye appendages (H00-H59).

  • Ocular migraine (synonyms: Ophthalmic migraine; Migraine ophtalmique) – variant of migraine in which transient, bilateral visual disturbances (flickering, flashes of light, scotomas (restrictions of the visual field); similar to “normal” migraine with aura) occur; often without headache, but sometimes with headache, which sometimes occurs only after the visual disturbances; duration of symptoms usually 5-10 minutes, rarely longer than 30-60 minutes Retinal migraine, in which only the retina, i.e. the retina at the back of the eye, is affected, must be distinguished from ocular migraine. i.e., the retina at the back of the eye, is affected – variant of migraine in which completely reversible monocular (“affecting one eye”), positive and/or negative visual phenomena (flickering, scotomas, or blindness) occur; these occur together with headaches that begin while the visual disturbances are still present or follow within 60 minutes
  • Glaucoma attack* – eye disease with increased intraocular pressure.
  • Overexertion of the eyes

Blood-forming organs – immune system (D50-D90)

  • Coagulopathy – disorder of blood clotting.

Endocrine, nutritional, and metabolic diseases (E00-E90).

Cardiovascular system (I00-I99)

  • Aneurysm (vascular dilatation) of cerebral vessels.
  • Apoplexy (stroke); usually not a typical leading symptom of ischemic stroke
  • Arteriovenous malformations (AVM) – congenital malformation of blood vessels, in which the arteries are directly connected to the veins; these occur mainly in the CNS and facial skull area.
  • Dissection (splitting of vessel wall layers) of the vessels supplying the brain.
  • Hypertension (high blood pressure), severe or hypertensive crisis.
  • Intracranial hemorrhage (bleeding within the skull; parenchymal, subarachnoid, sub- and epidural, and supra- and infratentorial hemorrhage)/intracerebral hemorrhage (ICB; cerebral hemorrhage).
  • Reversible cerebral vasoconstriction syndrome (RCVS; synonym: Call-Fleming syndrome) – in which constriction (contraction) of cerebral vessels results in severe headache (annihilation headache) with or without other neurologic abnormalities
  • Sinus vein thrombosis (SVT) – occlusion of a cerebral sinus (large venous blood vessels of the brain arising from duraduplications) by a thrombus (blood clot); clinical picture: headache, congestive papules and epileptic seizures.
  • Subarachnoid hemorrhage (SAB; hemorrhage between the spinal meninges and the soft meninges; incidence: 1-3%); symptomatology: proceed according to “Ottawa rule for subarachnoid hemorrhage”:
    • Age ≥ 40 years
    • Meningismus (symptom of painful neck stiffness in irritation and disease of the meninges).
    • Syncope (brief loss of consciousness) or impaired consciousness (somnolence, sopor and coma).
    • Onset of cephalgia (headache) during physical activity.
    • Thunderclap headache/destructive headache (about 50% of cases).
    • Restricted mobility of the cervical spine (Cervical spine).
  • Subdural hematoma (SDH) – hematoma (bruise) between the dura mater and the arachnoid membrane (spider membrane; middle meninges between the dura mater (hard meninges; outermost meninges) and the pia mater); symptoms: uncharacteristic complaints such as a feeling of pressure in the head, cephalgia (headache), vertigo (dizziness), restriction or loss of orientation and ability to concentrate; risk group: patients under anticoagulation (anticoagulants)
  • Vasculitis (vascular inflammation).
  • Cerebral venous and sinus thrombosis (CVT); symptoms: most severe, acute onset, circumscribed headache; possibly also focal or generalized cerebral deficits (incidence (frequency of new cases): < 1.5/100,000 per year).

Infectious and parasitic diseases (A00-B99).

  • Infections, unspecified
  • Meningitis (inflammation of the meninges), unspecified

Mouth, esophagus (esophagus), stomach, and intestines (K00-K67; K90-K93).

  • Dental diseases, unspecified

Musculoskeletal system and connective tissue (M00-M99).

  • Arteritis temporalis (synonyms: Arteriitis cranialis; Horton’s disease; giant cell arteritis; Horton-Magath-Brown syndrome) – systemic vasculitis (vascular inflammation) affecting the arteriae temporales (temporal arteries), especially in the elderly → urgent indication for biopsy and glucocorticoid administration.
  • Costen’s syndrome of the temporomandibular joint
  • Paget’s disease (disease of the skeletal system with bone remodeling) of the skull
  • Spondylosis (degenerative changes in vertebral bodies (and intervertebral spaces)) of the cervical spine (cervical spine).

Neoplasms – tumor diseases (C00-D48).

Ears – mastoid process (H60-H95).

  • Mastoiditis – inflammation of the aerated bone cells of the mastoid process (mastoid process).
  • Otitis (ear infection)

Psyche – nervous system (F00-F99; G00-G99)

  • Drug-induced headache*
  • Bruxism (teeth grinding) – unconscious, usually nocturnal, but also daytime repetitive masticatory muscle activity that occurs through grinding or clenching of the teeth or Tension or pressing of the jaws occurs; typical consequences are morning muscular pain, hypertrophy of the musculus masseter (masseter muscle), abrasions (loss of tooth structure), wedge-shaped defects of the teeth, root resorptions (degradation of root cement or cement and dentin in the area of one or more tooth roots) and possibly also temporomandibular joint disorders.
  • Chronic meningitis (meningitis).
  • Chronic hemiplegic headache
  • Chronic paroxysmal hemicrania – hemiparietal headache; attacks spread throughout the year with a maximum of one month of headache-free time.
  • Cluster headache
  • End-menstrual migraine (EMM; English : Non-Hormonally Mediated Cyclic Headache) – headache attacks not classically at the beginning of the period (= menstrual migraine) but in the last days of menstruation; in 28 of the 30 EMM patients (93.3%) the ferritin value was below the threshold of 50 ng/ml (50% was even < 18 ng/ml). Patients with iron deficiency anemia also have a high frequency of migraine headaches
  • Encephalitis (brain inflammation).
  • Glossopharyngeal neuralgia – neuralgia (nerve pain) that can occur due to partial attack pain in the hypophyarynx (lowest part of the pharynx), base of the tongue, tonsils (tonsils) and ear region with appropriate irritation, for example, chewing, swallowing, speaking (very rare!).
  • Brain abscess – encapsulated collection of pus in the brain.
  • Hydrocephalus (hydrocephalus; pathological enlargement of the liquid-filled fluid spaces (cerebral ventricles) of the brain).
  • Idiopathic intracranial hypertension (IIH; pseudotumor cerebri) – CSF pressure increase in the head without evidence of intracranial (“inside the skull“) space or acute thrombosis of venous blood vesselsNote: Approximately 10% of patients with refractory chronic daily headaches may have intracranial hypertension; CSF pressure measurement should be performed even in the absence of clinically manifest congestive papillae.
  • Insomnia (sleep disturbances) – cephalgia due to sleep deprivation.
  • Tension-type headache (tension headache).
  • Commotion syndrome (mild traumatic brain injury).
  • CSF hypotension syndrome – after CSF punctures (nerve water punctures) or epidural anesthesia with accidental dural perforation, postoperatively in spinal cord surgery, after trauma (eg, traumatic brain injury, TBI).
  • Meningitis (meningitis).
  • Meningoencephalitis (combined inflammation of the brain (encephalitis) and meninges (meningitis)).
  • Menstrual migraine (migraine without aura, whose attacks occur in at least two of three cycles in the days around menstruation; frequency: about 10-15% of women).
  • Migraine
  • Coin headache (Engl “nummular headache”); clinical picture: pain confined to a small, coin-sized area of the scalp (about 1-6 cm in size); continuous pain, which may be interrupted by symptom-free intervals (very rare).
  • Obstructive sleep apnea syndrome* – 11-40% of these patients complain of mostly morning holocephalic (“affecting the whole head“) headaches.
  • Occlusion disorders – disorders of the tooth row closure.
  • Postherpatic neuralgia (PNH) – nerve pain after herpes zoster infection.
  • Postpuncture headache (PPKS, PKS), also called postspinal or postdural headache, post-dural puncture headache, cerebrospinal fluid hypotension syndrome; English post-dural puncture headache (PDPH) or post-lumbar puncture headache (PLPH) Note: Major puncture occurs in 0.3 to 1.5% of parturients, from which postpuncture headache develops in 50 to 70% of cases. Clinical picture: pain occurs in the upright position and improves when lying down, each within 15 minutes.
  • Reversible posterior leukoencephalopathy (PRES) – occurrence of acute encephalopathy (brain disease) with headache, vision loss, epileptic seizures, impaired consciousness, and posterior subcortical cerebral edema (brain swelling).
  • Tension headache
  • Spontaneous low cerebrospinal fluid pressure syndrome (SLUDS; idiopathic low cerebrospinal fluid pressure syndrome) – diagnostic criteria (HS Classification ICHD-II are:A. Diffuse and/or dull headache that intensifies within less than 15 minutes after sitting up or standing up, is accompanied by at least one of the following symptoms, and fulfills criterion D:
    • Meningismus (neck stiffness).
    • Tinnitus (ringing in the ears)
    • Hypacusis (hearing loss)
    • Photophobia (photophobia)
    • Nausea (nausea)

    B. At least one of the following is present:

    • Signs of CSF hypotension on MRI (e.g., pachymeningeal enhancement).
    • Evidence of a CSF leak (defect in the spinal cord skin) by conventional myelography, CT myelography, or cisternography
    • CSF opening pressure in a sitting position

    C. History of no evidence of dural puncture (of the meninges) or other cause of CSF fistula (connection between the CSF system and the outside world).D. Headache resolves within 7 days after application of an epidural blood patch.

  • SUNCT syndrome (shortlasting unilateral neuralgiform headache attacks with conjunctival injection, tearing, sweating and rhinorrhea). – Headache with shorter attacks and higher frequency than cluster headache.
  • Trigeminal neuralgia* – usually unexplained severe pain in the face due to irritation of a facial nerve.
  • Cerebral ischemia* – reduced blood flow to the brain.

Pregnancy, childbirth and puerperium (O00-O99).

  • EPH-gestosis (impending eclampsia, i.e., most severe manifestation of gestosis associated with seizure or profound unconsciousness).

Injuries, poisonings, and other sequelae of external causes (S00-T98).

  • Carbon monoxide poisoning
  • Methanol poisoning
  • Intracranial hemorrhage (cerebral hemorrhage)
  • Posttraumatic headache – headache that occurs after trauma (injury).
  • Traumatic brain injury (TBI).
  • Traumatic corneal lesions – injuries to the cornea, due to an accident or surgery.
  • Injuries of the cervical spine

* Headache disorders with initial manifestation in older age.

Medication

Environmental pollution – intoxications (poisonings).

  • Climatic influences (eg, heat).

Further

  • Nutrition
    • Intake of cheese, chocolate
    • Lack of fluid intake (esp. in children and adolescents).
  • Stimulants
    • Alcohol
  • Psycho-social situation
    • Stress
    • Lack of sleep (esp. in children and adolescents).