Headache differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sabeeh Islam, MBBS[2]


Disease History and Physical Examination PMHx Diagnostic approach
Unilateral Bilateral Throbbing character Autonomic symptoms Fever Photophobia Aphasia LOC Aura Nause/vomiting Rash Neck stiffness Vision changes Facial tenderness Neurologic deficits Labs and CSF findings CT/MRI Gold standard test
Migraine + - + - - + - - + + - - + - - Trigger factors, family hx - - Clinical assesment
Tension-type headache (TTH) - + - - - - - - - - - - - - - stress, genetics - - Clinical assesment
Cluster headache + - - + - - - - - - - - + - - episodic history - - Clinical assesment
Seizure - + - - - - +/- + +/- - - - - - +/- Hx of seizures prolactin level +/- mass lesion EEG [1]
Meningitis - + - - + +/- +/- - - +/- +/- + - - + Hx of fever, malaise <math>\uparrow</math>WBC

<math>\uparrow</math>Protein

<math>\downarrow</math>glucose

+/- CSF analysis[2]
Encephalitis - + +/- - + +/- +/- - - - +/- + - - + Hx of fever, malaise elevated WBC, low glucose + CSF PCR
Brain tumor[3] - + - - - - +/- - - +/- - - +/- - +/- weight loss, fatigue neuromarkers,

Cancer cells[4]

+/- mass MRI
Subdural hemorrhage -/+ -/+ +/- - - - +/- - - - - - +/- - +/- Trauma, fall Xanthochromia + CT w/o contrast
Subarachnoid hemorrhage -/+ + +/- - - +/- +/- - - - - +/- +/- - +/- thunderclap headache <math>\uparrow</math>opening pressure, xanthochromia + CT w/o contrast
Hypertensive encephalopathy - + +/- - - +/- - - - - - - +/- - - Hypertension UA +/- +/- clinical assessment
CNS abscess -/+ -/+ - - + - +/- - - +/- +/- +/- +/- - +/- History of drug abuse, endocarditis, immunosupression ↑ leukocytes, ↓ glucose and ↑ protien + MRI
Conversion disorder -/+ -/+ - - - - +/- - - - - +/- +/- - +/- History of emotional stress - - Diagnosis of exclusion
Multiple sclerosis -/+ -/+ - - - - - - - - - - + - +/- History of relapses and remissions ↑ CSF IgG levels

(monoclonal bands)

+ MRI
Hemorrhagic stroke -/+ -/+ +/- - - - +/- - - - - - +/- - +/- HTN - + CT scan without contrast[5][6]
Neurosyphilis[7][8] -/+ -/+ - - - - - +/- - - +/- - +/- - +/- STIs ↑ Leukocytes and protein + CSF VDRL-specifc

CSF FTA-Ab -sensitive[9]

Wernicke’s encephalopathy - -/+ - - - - +/- - - - - - +/- - +/- History of alcohal abuse blood ethanol levels +/- Clinical assesment and lab findings
Drug toxicity - -/+ - - +/- - - +/- - +/- - +/- +/- - +/- Medication hx Drug levels - Drug screen test
Metabolic disturbances - -/+ - - - - - - - +/- - - +/- - +/- Underlying CKD, CLD Hypoglycemia, hypo and hypernatremia, hypo and hyperkalemia - Cause dependent
NPH - -/+ - - - - - - - - - - +/- - - OCP use, meds - +/- CT and clinical
Sinusitis - -/+ - - +/- - - - - - - - - - - allergies, seasonal leukocytosis + CT

Diagnsotic Labs For Meningitis

Diagnosis of meningitis, is based on clinical presentation in combination with CSF analysis. CSF analysis has major role for diagnosis and rule out other possibilities. The following table summarizes the CSF findings in different types of meningitis.[10][11][12][13][14]

Cerebrospinal fluid level Normal level Bacterial meningitis[13] Viral meningitis[13] Fungal meningitis Tuberculous meningitis[15] Neoplastic meningitis[10]
Cells/ul < 5 >300 10-1000 10-500 50-500 >4
Cells Lymphocyte Leukocyte > Lymphocyte Lymphocyte > Leukocyte Lymphocyte > Leukocyte Lymphocyte > Leukocyte Lymphocyte > Leukocyte
Total protein (mg/dl) 45-60 Typically 100-500 Normal or slightly high High Typically 100-200 >50
Glucose ratio (CSF/plasma)[11] > 0.5 < 0.3 > 0.6 <0.3 < 0.5 <0.5
Lactate (mmols/l)[12] < 2.1 > 2.1 < 2.1 >3.2 > 2.1 >2.1
Others Intra-cranial pressure (ICP) = 6-12 (cm H2O) CSF gram stain, CSF culture, CSF bacterial antigen PCR of HSV-DNA, VZV CSF gram stain, CSF india ink PCR of TB-DNA CSF tumour markers such as alpha fetoprotein, CEA


References

  1. ↑ Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.
  2. ↑ Carbonnelle E (2009). "[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]". Med Mal Infect. 39 (7–8): 581–605. doi:10.1016/j.medmal.2009.02.017. PMID 19398286.
  3. ↑ Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
  4. ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  5. ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  6. ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  7. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  8. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  9. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  10. ↑ 10.0 10.1 Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.
  11. ↑ 11.0 11.1 Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
  12. ↑ 12.0 12.1 Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
  13. ↑ 13.0 13.1 13.2 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
  14. ↑ Brouwer MC, Tunkel AR, van de Beek D (2010). "Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis". Clin Microbiol Rev. 23 (3): 467–92. doi:10.1128/CMR.00070-09. PMC 2901656. PMID 20610819.
  15. ↑ Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.


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