COVID-19-associated headache differential diagnosis

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


Overview

COVID-19-associated headache must be differentiated from other diseases that cause headache, such as migraine, tension-type headache, cluster headache, seizure, meningitis, encephalitis, neurosyphilis, SAH, subdural hematoma, brain tumor, hypertensive encephalopathy, brain abscess, multiple sclerosis, hemorrhagic stroke, Wernickes encephalopathy, and drug toxicity etc.

Differential Diagnosis

COVID-19-associated headache must be differentiated from other diseases that cause headache, such as migraine, tension-type headache, cluster headache, seizure, meningitis, encephalitis, neurosyphilis, SAH, subdural hematoma, brain tumor, hypertensive encephalopathy, brain abscess, multiple sclerosis, hemorrhagic stroke, Wernickes encephalopathy, and drug toxicity etc.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]

Disease History and Physical Examination PMHx Diagnostic approach
Bilateral Throbbing character Autonomic symptoms Fever Photophobia Aphasia LOC Aura Nause/

Vomiting

Rash Neck stiffness Vision changes 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 [20]
Meningitis + - - + +/- +/- - - +/- +/- + - + Hx of fever, malaise <math>\uparrow</math>WBC

<math>\uparrow</math>Protein

<math>\downarrow</math>glucose

+/- CSF analysis[21]
Encephalitis + +/- - + +/- +/- - - - +/- + - + Hx of fever, malaise elevated WBC, low glucose + CSF PCR
Brain tumor[22] + - - - - +/- - - +/- - - +/- +/- weight loss, fatigue neuromarkers,

Cancer cells[23]

+/- 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[24][25]
Neurosyphilis[26][27] -/+ - - - - - +/- - - +/- - +/- +/- STIs ↑ Leukocytes and protein + CSF VDRL-specifc

CSF FTA-Ab -sensitive[28]

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
Sinusitis -/+ - - +/- - - - - - - - - - allergies, seasonal leukocytosis + CT

References

  1. ↑ "National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage". Ann. Clin. Biochem. 40 (Pt 5): 481–8. September 2003. doi:10.1258/000456303322326399. PMID 14503985.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
  6. ↑ 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.
  7. ↑ Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J (July 1989). "Xanthochromia after subarachnoid haemorrhage needs no revisitation". J. Neurol. Neurosurg. Psychiatry. 52 (7): 826–8. doi:10.1136/jnnp.52.7.826. PMC 1031927. PMID 2769274.
  8. ↑ Wasay M, Mekan SF, Khelaeni B, Saeed Z, Hassan A, Cheema Z, Bakshi R (June 2005). "Extra temporal involvement in herpes simplex encephalitis". Eur. J. Neurol. 12 (6): 475–9. doi:10.1111/j.1468-1331.2005.00999.x. PMID 15885053.
  9. ↑ Glaser CA, Honarmand S, Anderson LJ, Schnurr DP, Forghani B, Cossen CK, Schuster FL, Christie LJ, Tureen JH (December 2006). "Beyond viruses: clinical profiles and etiologies associated with encephalitis". Clin. Infect. Dis. 43 (12): 1565–77. doi:10.1086/509330. PMID 17109290.
  10. ↑ Meltzer EO, Hamilos DL (May 2011). "Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines". Mayo Clin. Proc. 86 (5): 427–43. doi:10.4065/mcp.2010.0392. PMC 3084646. PMID 21490181.
  11. ↑ Rasmussen BK, Jensen R, Schroll M, Olesen J (1991). "Epidemiology of headache in a general population--a prevalence study". J Clin Epidemiol. 44 (11): 1147–57. doi:10.1016/0895-4356(91)90147-2. PMID 1941010.
  12. ↑ Kelman L (October 2004). "The premonitory symptoms (prodrome): a tertiary care study of 893 migraineurs". Headache. 44 (9): 865–72. doi:10.1111/j.1526-4610.2004.04168.x. PMID 15447695.
  13. ↑ Laurell K, Artto V, Bendtsen L, Hagen K, Häggström J, Linde M, Söderström L, Tronvik E, Wessman M, Zwart JA, Kallela M (September 2016). "Premonitory symptoms in migraine: A cross-sectional study in 2714 persons". Cephalalgia. 36 (10): 951–9. doi:10.1177/0333102415620251. PMID 26643378.
  14. ↑ Charlotte E. Grayson and The Cleveland Clinic Neuroscience Center (October 2004). "Cluster Headaches". WebMD. Retrieved 2006-09-22.
  15. ↑ Drummond PD (October 1994). "Sweating and vascular responses in the face: normal regulation and dysfunction in migraine, cluster headache and harlequin syndrome". Clin. Auton. Res. 4 (5): 273–85. doi:10.1007/BF01827433. PMID 7888747.
  16. ↑ Drummond PD (June 2006). "Mechanisms of autonomic disturbance in the face during and between attacks of cluster headache". Cephalalgia. 26 (6): 633–41. doi:10.1111/j.1468-2982.2006.01106.x. PMID 16686902.
  17. ↑ Ekbom K (August 1990). "Evaluation of clinical criteria for cluster headache with special reference to the classification of the International Headache Society". Cephalalgia. 10 (4): 195–7. doi:10.1046/j.1468-2982.1990.1004195.x. PMID 2245469.
  18. ↑ Sandrini G, Antonaci F, Pucci E, Bono G, Nappi G (December 1994). "Comparative study with EMG, pressure algometry and manual palpation in tension-type headache and migraine". Cephalalgia. 14 (6): 451–7, discussion 394–5. doi:10.1046/j.1468-2982.1994.1406451.x. PMID 7697707.
  19. ↑ Jensen R, Fuglsang-Frederiksen A (June 1994). "Quantitative surface EMG of pericranial muscles. Relation to age and sex in a general population". Electroencephalogr Clin Neurophysiol. 93 (3): 175–83. doi:10.1016/0168-5597(94)90038-8. PMID 7515793.
  20. ↑ Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.
  21. ↑ 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.
  22. ↑ Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
  23. ↑ 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.
  24. ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  25. ↑ 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.
  26. ↑ 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.
  27. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  28. ↑ 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.
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