Migraine Headache Differential Diagnoses

  • Author: Jasvinder Chawla, MBBS, MD, MBA; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: May 25, 2011
 
 

Diagnostic Considerations

When headache is episodic and recurrent and follows a well-established pattern, the patient likely has a primary headache disorder (ie, headaches with no organic or structural etiology). Differentiating migraine from other primary headaches (eg, muscle contraction tension headache, cluster headache) is important, as optimal treatment may differ.

Migraine may also may simulate or be simulated by secondary headache disorders or coexist with a secondary headache disorder. Any of the following features suggest a secondary headache disorder and warrant further investigation:

  • The first or worst headache of the patient's life, especially if rapid in onset
  • A change in frequency, severity, or clinical features of the attack from what the patient usually experiences
  • New progressive headache that persists for days
  • Precipitation of headache with Valsalva maneuvers (ie, coughing, sneezing, bearing down)
  • The presence of associated neurological signs or symptoms (eg, diplopia, loss of sensation, weakness, ataxia)
  • Onset of headaches after the age of 55 years
  • Headache developing after head injury or major trauma
  • Persistent one-sided throbbing headaches
  • Headaches that are associated with stiff neck or fever
  • Atypical history or unusual character that does not fulfill the criteria for migraine
  • Inadequate response to optimal therapy

Crash migraine

Severe headache of sudden onset is a concern despite its occurrence in primary headache disorders. Migraine headaches may have an abrupt onset; these are termed "crash" migraine and are similar to a "thunderclap" headache. Cluster headache also may be sudden and excruciating, but it lasts only 15-180 minutes and is recognized easily if the patient has had previous attacks.

Exertional headache

Exertional headache builds in intensity over minutes and occurs with sustained physical exertion. Coital headache can develop at the height of orgasm or it may build up through intercourse.

Intracranial aneurysm

Despite these possibilities, a ruptured intracranial aneurysm is the primary consideration if the headache is severe with sudden onset and reaches maximum intensity in minutes. The classical presentation of an aneurysmal subarachnoid hemorrhage (SAH) is a severe headache with sudden, explosive onset, stiff neck, photophobia, nausea and vomiting, and possibly alteration of consciousness.

An extensive evaluation is indicated in such cases, including initial CT scan of the head without contrast. Lumbar puncture (LP) should be considered if CT scan is negative, as 25% of cases are missed by CT. Questions remain over whether an angiogram should be performed if the patient has normal findings on neurologic examination, cerebrospinal fluid (CSF) examination, and CT or MRI.

In one study, acute severe thunderclap headache comparable to that of SAH without the nuchal rigidity occurred in 6.3% of patients with unruptured aneurysm. Other studies have revealed that in patients with severe thunderclap headache with normal CT and CSF findings, none developed SAH.[51]

If the CT scan and LP are performed late after symptom onset, so that negative results are unreliable, and if clinical features such as family history or past medical history, classic SAH-like symptoms, or the presence of neurological signs (in particular a third cranial nerve palsy affecting the pupil) suggest that the patient is at risk, angiography should probably be performed if an experienced angiographer is available.

In patients with unrevealing studies in whom the diagnosis of aneurysmal SAH is possible but very unlikely, MRI and magnetic resonance angiography (MRA) are screening tests, and close follow-up is appropriate if the findings of these tests are negative.

Space-occupying lesion

Another concern is the possibility of a space-occupying lesion mimicking migraine. In a series of 111 patients with primary (34%) or metastatic (66%) brain tumor, headache was reported in 48%; the headache had characteristics similar to migraine in 9% and to tension-type headache in 77%, while the so-called classic brain tumor headache occurred in only 17%. Headache was intermittent in 62%, usually lasting a few hours.

All patients with headaches similar to migraine had other neurological symptoms or abnormal signs. Of note is that 32% had history of headache; in 36% of those, the headache was of identical character to prior headaches but was more severe or frequent and was associated with other symptoms such as seizures, confusion, prolonged nausea, and hemiparesis.[52]

These data indicate that patients with a history of headache should have further diagnostic workup if the headache is accompanied by new symptoms or abnormal signs or differs in any way from their usual headache. With new-onset headache, imaging should be obtained if headache is severe or occurs with nausea, vomiting, or abnormal signs.

Other space-occupying lesions must be considered in the appropriate clinical setting. Large intraparenchymal hemorrhage presents dramatically with headache and neurological symptoms or signs shortly after onset. Of patients with chronic, subacute, or acute subdural hematoma, 81%, 53%, and 11%, respectively, have headaches. In brain abscesses, a progressive, severe, intractable headache is common, and headache is reported in 70-90% of patients.

Cerebral venous thrombosis

Cerebral venous thrombosis involves the sagittal sinus in about 70% of cases; these patients present with signs and symptoms of increased intracranial pressure (ICP), such as headache and papilledema. Should the thrombus extend to the superficial cortical veins, then focal findings may be noted. In the appropriate setting with known risk factors, cerebral venous thrombosis must be considered and evaluated with MRI, MRA, or magnetic resonance venography (MRV).

Spontaneous internal carotid artery dissection

Spontaneous internal carotid artery dissection is an uncommon cause of headache and acute neurological deficit, but it must be considered in the younger individuals who have unilateral, severe, persistent head pain of sudden onset preceding neurological signs, most commonly Horner syndrome, differentiating it from traumatic causes, in which cerebral ischemic symptoms are more common.

Other secondary causes

Other secondary causes of alarming headaches should be sought in the presence of the "red flags" mentioned above and must be sought in the appropriate clinical setting. Other features needing further diagnostic workup include positional headaches, which may occur in colloid cysts or other ventricular tumors such as ependymomas, Chiari malformations, and low CSF pressure headache.

Headaches after age 50 years must be investigated to consider temporal or giant cell arteritis. Headaches associated with systemic disease require consideration of infectious and non-infectious inflammatory processes.

Bear in mind that sumatriptan and related compounds, by virtue of being able to block expression of c-fos by their action on 5-HT1 receptors, decrease headaches with diverse pathogenesis. These agents may be effective in decreasing headache pain associated with meningovascular irritation, such as viral and bacterial infections and subarachnoid hemorrhage. Hence, response to 5-HT1 agonists is not diagnostic of a migraine headache.

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Jasvinder Chawla, MBBS, MD, MBA  Chief of Neurology, Hines Veterans Affairs Hospital; Associate Professor and Director, Neurology Residency Training Program, Loyola University Medical Center

Jasvinder Chawla, MBBS, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Blanda, MD  Chair, Department of Emergency Medicine, Summa Health System Akron City/St. Thomas Hospital; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

Michelle Blanda, MD, is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ronald Braswell, MD  Associate Professor, Department of Ophthalmology, University of Alabama-Birmingham

Ronald Braswell, MD is a member of the following medical societies: American Academy of Ophthalmology and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Joseph Carcione Jr, DO, MBA  Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans

Joseph Carcione Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Jane W Chan, MD  Professor of Neurology/Neuro-ophthalmology, Department of Medicine, Division of Neurology, University of Nevada School of Medicine

Jane W Chan, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Medical Association, North American Neuro-Ophthalmology Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Eric R Eggenberger, DO, MS, FAAN  Professor, Vice-Chairman, Department of Neurology and Ophthalmology, Colleges of Osteopathic Medicine and Human Medicine, Michigan State University; Director of Michigan State University Ocular Motility Laboratory; Director of National Multiple Sclerosis Society Clinic, Michigan State University

Eric R Eggenberger, DO, MS, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Osteopathic Association, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Jacqueline Freudenthal, MD  Co-Investigator, Ophthalmic Consultants Centre, Toronto

Jacqueline Freudenthal, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, and Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Deborah I Friedman, MD, MPH  Professor of Ophthalmology and Neurology, University of Rochester School of Medicine and Dentistry; Consulting Staff, Strong Memorial Hospital

Deborah I Friedman, MD, MPH is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Headache Society, American Neurological Association, Association for Research in Vision and Ophthalmology, North American Neuro-Ophthalmology Society, Society for Neuroscience, and United Council of Neurologic Subspecialties, Certification in Headache Medicine

Disclosure: MAP Pharmaceuticals Grant/research funds Site PI (through university); AGA Medical Grant/research funds Site PI (through university); Teva Grant/research funds Site PI (through university); Pfizer Grant/research funds Site PI; Neurology Reviews Honoraria Editorial board; Merck Grant/research funds Site PI

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Edsel Ing, MD, FRCSC  Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Toronto East General Hospital, Canada

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

David Y Ko, MD  Associate Professor of Clinical Neurology, Associate Director, USC Adult Epilepsy Program, Keck School of Medicine of the University of Southern California

David Y Ko, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Headache Society

Disclosure: GSK Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching; Lundbeck Consulting fee Consulting; Westward Consulting fee Consulting

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Soma Sahai-Srivastava, MD  Director of Neurology Ambulatory Care Services, LAC and USC Medical Center; Assistant Professor, Department of Neurology, Keck School of Medicine of the University of Southern California

Soma Sahai-Srivastava, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, and American Medical Association

Disclosure: Nothing to disclose.

Jeff T Wright, MD  Instructor, Department of Emergency Medicine, Summa Health System; Corporation President and Consulting Staff, Summa Emergency Associates, Inc

Jeff T Wright, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Brian R Younge, MD  Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Robert A Egan, MD  Director of Neuro-Ophthalmology, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

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Migraine headache. Example of a visual migraine aura as described by a person who experiences migraines. This patient reported that these visual auras preceded her headache by 20-30 minutes.
Migraine headache. Example of a central scotoma as described by a person who experiences migraines. Note the visual loss in the center of vision.
Migraine headache. Example of a central scotoma as described by a person who experiences migraine headaches. Again note the visual loss in the center of vision.
Migraine headache. Example of visual changes during migraine. Multiple spotty scotomata are described by a person who experiences migraines.
Migraine headache. Frank visual field loss can also occur associated with migraine. This example shows loss of the entire right visual field as described by a person who experiences migraines.
International Headache Society criteria for migraine.
Overview of migraine treatment. Five steps.
International Headache Society (IHS) classification of secondary headaches.
Table 1. Abortive Medication Stratification by Headache Severity
Moderate Severe Extremely Severe
NSAIDsNaratriptanDHE (IV)
IsomethepteneRizatriptanOpioids
ErgotamineSumatriptan (SC,NS)Dopamine antagonists
NaratriptanZolmitriptan
RizatriptanAlmotriptan
SumatriptanFrovatriptan
ZolmitriptanEletriptan
AlmotriptanDHE (NS/IM)
FrovatriptanErgotamine
EletriptanDopamine antagonists
Dopamine antagonists
Table 2. Preventive Drugs
First lineHigh efficacyBeta-blockers



Tricyclic antidepressants



Divalproex



Topiramate



Low efficacyVerapamil



NSAIDs



SSRIs



Second lineHigh efficacyMethysergide



Flunarizine



MAOIs



Unproven efficacyCyproheptadine



Gabapentin



Lamotrigine



Table 3. Preventive Medication for Comorbid Conditions
Comorbid Condition Medication
HypertensionBeta-blockers
AnginaBeta-blockers
StressBeta-blockers
DepressionTricyclic antidepressants, SSRIs
UnderweightTricyclic antidepressants
EpilepsyValproic acid, Topiramate
ManiaValproic acid
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