Photophobia and Headache - Differential Diagnosis Framework
Why?
• The coexistence of photophobia and headache suggests the potential reciprocal interactions between visual and pain pathways.
• Interactions between visual and pain pathways occur at the retina, midbrain, thalamus, hypothalamus, and visual cortex.
• In migraines: photophobia could result from photic activation of retina-driven pathways involved in the regulation of homeostasis.
Primary headaches:
• Migraine:
- 80 percent of people who have migraines have photophobia
- Bilateral photophobia
- Severe persistent photophobia
- Migraine with aura > migraine without aura
- Chronic migraine > episodic migraine
- Benign episodic mydriasis, miosis
• Tension-type headache:
- Bilateral or unilateral photophobia
- Mild persistent photophobia
• Trigeminal autonomic cephalalgias (TACs):
- Hemicrania continua, SUNCT, SUNA, etc.
- Unilateral
- Reversible, only during their cluster period
- Moderate, between migraine and tension-type headache
- Autonomic symptoms
- Miosis
Secondary headaches:
• Traumatic brain injury (TBI):
- Reversible or persistent photophobia
• Meningitis:
- Patients tend to have meningeal irritation signs
- Photophobia in viral meningitis is the most common form
• Non-traumatic subarachnoid hemorrhage (SAH):
- Mydriasis
- Can have isolated photophobia without headache
• Disorder of the eyes - Photophobia often precedes the onset of headache:
- Acute angle-closure glaucoma
- Ocular inflammatory disorder
- Trochlear headache
• CNS Vasculitis
Painful cranial neuropathies:
• Trigeminal neuralgia:
- Common in patients with the first division of the trigeminal nerve pain
- Mydriasis
• Painful optic neuritis
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