Differential Diagnosis of Common Neurological Symptoms


What else could it be? While presence of a Chiari I malformation can be confirmed on an MRI scan, its discovery does not necessarily confirm it as the cause of the patient’s symptoms. Diane Mueller, ND, RN, FNP-BC, a provider with many years of experience in evaluating and caring for persons with CMI, offers guidance when considering other neurological disorders that may be responsible for the patient's symptoms.  

Healthcare providers are often faced with a patient who presents with multiple neurological complaints. Many of the presenting symptoms can be vague or insidious, leading to a diagnostic conundrum. Once the patient has an MRI that shows radiographic evidence of Chiari I malformation, it is often assumed (by both patients and providers) that all of their symptoms can be attributable to CMI. The most common symptom of CMI is posterior occipital headache (often triggered or worsened by valsalva). Other predominant symptoms include: neck pain, dizziness, fatigue, memory and concentration difficulty, parasthesias, dysphasia and visual disturbances (1).

When faced with these myriad of symptoms, it is often difficult to decipher what is attributable to CMI and what other possible causes can be the culprit. Many medications, both prescribed and over-the-counter, as well as medical co-morbidities can cause symptoms that mimic the symptoms of CMI.

When the provider suspects the clinical presentation is not fully compatible with the findings on MRI, the outstanding symptom, or symptoms, can be checked with this list to consider other diagnostic possibilities.



Ataxia: Adrenal insufficiency, arsenic poisoning, Bechet’s disease, cerebellar abscess, CVA, diabetic neuropathy, encephalomyelitis, Friedreich’s ataxia, G-B syndrome, hepatocerebral degeneration, hydrocephalus, hypothyroid, medications, MS, myelopathy, NPH, OPC atrophy, pellagra, polyarteritis, polyneuropathy, post-polio syndrome, post-concussion syndrome, spinocerebellar ataxia, syringomyelia, tabes dorsalis, vitamin deficiency, Wernicke’s disease, Wilson’s disease

Blurred vision/diplopia: botulism, cavernous sinus thrombosis, congenital eye disorders, diabetes, encephalitis, HTN, hyperthyroid, intracranial mass lesion, medications, MS, MG, ophthalmic migraine, optic neuritis, orbital cellulitis, orbital myositis, pseudotumor cerebri, retinal detachment, thyrotoxicosis

Cognitive problems: alzheimers, anemia, anxiety, cardiac abnormalities, concussion, dementia, depression, hydrocephalus, hypotension, hypoxia, medications, MS, nutritional deficiency, PTSD, sleep disturbances, stress, stroke, Thyroid dysfunction, TIA, vascular insufficiency,

Dizziness: anemia, anxiety, botulism, cardiac dysrhythmia, carotid vascular disease, emphysema, endolymphatic hypertension, ETOH, HTN, hyperventilation syndrome, hypoglycemia, hypotension, hypoxia, intracranial mass, labyrinthitis, lead poisoning, medications, MS, panic disorder, postconcussion syndrome, sideroblastic anemia, TIA, vasovagal response, vertebrobasilar insufficiency

Dysarthria: ALS, basilar artery insufficiency, Botulism, hypoadrenalism, mercury poisoning, medications, MS, Myasthenia, OPC degeneration, Parkinson’s Disease, Shy-Drager Syndrome

Dysphagia: achalasia, ALS, basilar impression, botulism, bulbar paralysis, carcinoma, esophageal diverticulum, esophageal spasm, esophagitis, G-B syndrome, hiatal hernia, hypoparathyroidism, hypocalcemia, lead poisoning, Lupus, mediastinitis, Myasthenia Gravis, pharyngitis, progressive systemic sclerosis, rabies, syphilis, Tetanus

Dyspnea: ALS, altitude sickness, anemia, asthma, basilar impression, carcinoma, CHF, dysrhythmias, emphysema, Guillain-Barre syndrome, hyperthyroid, inhalation injury, interstitial fibrosis, Myasthenia, obesity, pneumonia, pulmonary edema, pulmonary edema, sideroblastic anemia, smoking, stress, vitamin B deficiency

Fatigue: ALS, anemia, chronic fatigue syndrome, depression, diabetes, fibromyalgia, hypothyroid/ hyperthyroid, hypotension, insomnia, hyperaldostronism, Lupus, niacin deficiency, hypercalcemia, hypoxia, intracranial lesion, iodine deficiency, G-B syndrome, lead  poisoning, medications, MS, Myasthenia Gravis, obesity, pituitary lesion, polycythemia vera, post-polio syndrome, sleep apnea, stress, systemic pain syndrome, vitamin deficiency,

Headache: allergies, arachnoid cyst, caffeine consumption or cessation, cervical spine disorders, cervical syringomyelia, cranio-cervical instability, EDH, ETOH, encephalitis, glaucoma, glossopharyngeal neuralgia, HTN, hyperaldosteronism, ICH, intracranial abscess, influenza, intracranial mass lesion, Lyme disease, medications, meningitis, migraine, muscle spasm of the head and neck,  niacin deficiency, obesity, occipital neuralgia, pheochromocytoma, polycythemia vera,  Pseudotumor cerebri, SDH, stress, TMJ, Pagets disease, post concussion syndrome, sinusitis, temporal arteritis, trigeminal neuralgia,  vascular malformation, vasospasm,

Hearing loss/tinnitus: acoustic neuroma, adenoid hypertrophy, allergies, aural polyps, cerumen impaction, cholesteatoma, cyst, Diabetes Mellitus, excessive noise or environmental factors, family history of hearing disorders, furuncle, granuloma, hypothyroidism, hysteria, iodine deficiency, Meniere’s Disease, mononucleosis, mumps, myringitis, nasopharyngeal cancer, Osteoma, otitis, ototoxic drugs, syphilis, temporal arteritis, TB, TM perforation, viral infections,

Hoarseness: basilar impression, carcinoma, cervical syringomyelia, esophageal diverticula, hypothyroid/hyperthyroid, hypoadrenalism, hysteria, idiopathic vocal cord paralysis, inhalation injury, iodine deficiency, laryngitis, metallic poisoning, mitral stenosis, neuritis, pulmonary TB, Rheumatoid arthritis, thoracic aortic aneurysm, trauma, vitamin B deficiency, vocal cord polyps, vocal tic disorder,

Insomnia: affective disorders, anxiety, depression, drugs (prescribed and OTC), ETOH withdrawal, nocturnal myoclonus, nocturnal hypoxia, chronic pain, Pheochromocytoma, pruritis, sleep apnea, Thyrotoxicosis

Muscle weakness: arsenic poisoning, beta-blockers, botulism, cervical spine disorders, chronic hypokalemia, chronic fatigue syndrome, diphtheria, diabetes, fibromyalgia, G-B syndrome,  hyperparathyroidism, hypomagnesemia, hypernatremia, HTN, hypotension, hypothyroid, Lead poisoning, Leukemia, Lyme disease, lupus, MS, Myasthenia Gravis, niacin deficiency, obesity, osteomalacia, poliomyelitis,  post-polio syndrome, renal failure, sarcoidosis, sideroblastic anemia, spinal cord tumor, syringomyelia, vitamin deficiency

Nystagmus: anticonvulsant toxicity, basilar impression, cerebellar ataxia, encephalitis, ETOH withdrawal, hypothyroid/hyperthyroid, intracranial lesion, intracranial abscess, iodine deficiency, medications, MS, Parinaud’s syndrome, pinealoma, pseudoparkinsonism, spinocerebellar degeneration, thiamine deficiency, vitamin B deficiency

Parasthesias: ALS, basilar invagination, cervical spine disorders, craniocervical instability, diabetes, G-B syndrome, hyperaldosteronism, hypoparathyroidism, hyperthyroid/hypothyroid, intracranial lesion, MS, Myasthenia Gravis, neuropathy, pheochromocytoma, post-polio syndrome, syringomyelia, vitamin deficiency

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  1. Prospective analysis of presenting symptoms among 265 patients with radiographic evidence of Chiari malformation type I with or without syringomyelia. J Am Acad Nurse Pract. 2004 Mar;16(3):134-8.
  2. Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery. 1999 May;44(5):1005-17.

John J. Oró, MDComment