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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