Clinical reference · Card 11 of 11 · Diagnostic delay
Why it gets missed
77%misdiagnosed at first consultationn=144, Italy
DIAGNOSES GIVEN INSTEAD
Trigeminal neuralgia22%
Other / dental21%
Migraine without aura19%
Sinusitis15%
FEATURES ASSOCIATED WITH DIAGNOSTIC DELAY · VAN VLIET 2003, N=1,163Photophobia, phonophobia, nausea and vomiting were all associated with longer delay — they read as migraine. In cluster headache, photophobia and phonophobia are typically unilateral, ipsilateral to the pain. Their presence does not exclude cluster headache.
FOUR QUESTIONS THAT SHORTEN THE DELAY
1Duration and frequency first — 15–180 minutes, up to 8 a day, is not migraine.
2What do you do during an attack? Pacing is close to pathognomonic; lying still is not.
3Same hour each day? Same weeks each year? Cluster is a circadian disorder.
4Does alcohol trigger an attack within minutes during a bout — and do nothing in remission?
2.6 yrsmean delay by the 1990s (22 years in the 1960s)
3 GPsseen before diagnosis (median, UK cohort)
55%report suicidal ideation (US survey, n=1,134)
SOURCES Voiticovschi-Iosob C et al. J Headache Pain 2014;15:56 (n=144). van Vliet JA et al. JNNP 2003;74:1123–5. Bahra A, Goadsby PJ. Acta Neurol Scand 2004;109:175–9. Rozen TD, Fishman RS. Headache 2012;52:99–113.
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