Differential Diagnosis and Workup for Pressure-like Constant Headache on Top of Head

Key Differential Diagnoses to Consider

The American Academy of Neurology suggests that tension-type headache is typically bilateral with pressing/tightening character, mild to moderate severity, and not aggravated by routine physical activity 2
The International Headache Society recommends considering migraine, which is often unilateral, throbbing, moderate to severe, worsened by activity, with associated symptoms like nausea/vomiting and photophobia/phonophobia 3
Spontaneous intracranial hypotension (SIH) should be considered if headache improves when lying flat and worsens when upright, as suggested by the Journal of Neurology, Neurosurgery and Psychiatry 4, 5
Cerebral venous thrombosis can present with increased intracranial pressure and headache, especially with risk factors like cancer or hypercoagulable states, according to Stroke 6
Intracranial mass lesions (tumors, arteriovenous malformations) should be considered, especially if associated with abnormal neurological examination, as recommended by the Journal of the American College of Radiology and the American Academy of Family Physicians 7, 8
Pseudotumor cerebri syndrome should be considered, particularly in overweight females with papilledema, according to the Journal of the American College of Radiology 7
Cervicogenic headache should be considered if provoked by cervical movement rather than posture, as suggested by the Journal of Neurology, Neurosurgery and Psychiatry 5

New onset headache in patients over 50 years of age requires urgent evaluation, as recommended by the American Academy of Family Physicians 8
Headache worsened by Valsalva maneuver or cough requires urgent evaluation, according to the American Academy of Family Physicians 8
Headache that awakens patient from sleep requires urgent evaluation, as suggested by the American Academy of Family Physicians 8
Abnormal neurological examination findings require urgent evaluation, as recommended by the Journal of the American College of Radiology and the American Academy of Family Physicians 7, 8

A detailed history should characterize the headache, including location, quality, severity, timing, aggravating/alleviating factors, and associated symptoms like nausea, vomiting, photophobia, and phonophobia, as recommended by Nature Reviews Neurology 3
A physical examination should include a complete neurological examination, including fundoscopy to check for papilledema, as suggested by the Journal of the American College of Radiology and Praxis Medical Insights 7, 1
Initial testing based on clinical suspicion may include brain MRI with and without contrast, basic laboratory tests, and lumbar puncture, as recommended by the American Academy of Family Physicians and Praxis Medical Insights 8, 1

Primary headache disorders can be treated with appropriate medications after secondary causes are ruled out, as suggested by Nature Reviews Neurology 3
Documenting headache patterns using a headache diary can aid in diagnosis and treatment monitoring, as recommended by Praxis Medical Insights 1
Consider specialist referral for atypical presentations, treatment-resistant cases, or when secondary causes are suspected, as suggested by the Journal of Neurology, Neurosurgery and Psychiatry 5

Assuming a chronic headache is always a primary headache disorder without considering secondary causes is a common pitfall, as warned by the Journal of Neurology, Neurosurgery and Psychiatry 4, 5
Ordering neuroimaging for typical primary headache presentations without red flags or abnormal examination findings is not recommended, as suggested by the American Academy of Family Physicians 8
Missing the diagnosis of SIH because the orthostatic component may not always be obvious is a common pitfall, as warned by the Journal of Neurology, Neurosurgery and Psychiatry 4, 5