When encountering patients with headaches in the emergency department, dangerous diseases that may threaten the patient's brain, limbs, vision and even life must be considered. Doctors need to stay alert when the patient has other warning symptoms or signs besides a headache. This article lists 10 dangerous causes of headaches for your reference.
For doctors in the emergency department, if the patient is in a stable condition, relieving pain and discomfort is the primary goal. However, the patient's headache is primary or secondary and cannot be judged by the patient's response to analgesic treatment. When the patient's pain is relieved, discovering and handling secondary causes is the top priority. If the patient presents with the 10 red flags mentioned below, the clinician should conduct further examination of the patient to check for the serious cause.
signal 1 headache + sudden attack/severe pain
patients with severe headache and sudden headache should complete neuroimaging examinations to rule out hemorrhagic stroke, including subarachnoid hemorrhage . If CT scan of does not show bleeding, consider lumbar puncture to clarify the cause.
For patients with so-called "pili-like headache", subarachnoid hemorrhage is indeed a diagnosis that needs to be ruled out. However, patients with pili-like headache may not only be the benign cause of reversible cerebrovascular contraction syndrome, but may also be caused by other life-threatening causes. Headache of any vascular origin in the artery or venous system may cause sudden onset of symptoms, such as carotid artery dissection and cerebral venous thrombosis, spontaneous intracranial hypotension, pituitary stroke , and hypertensive encephalopathy may also have such clinical manifestations.
In addition, for patients with sudden headaches and eye pain and abnormal vision, the possibility of acute angle-closure glaucoma should be taken into account, and a complete ophthalmic examination is required for such patients to clarify the diagnosis. In short, although it is important to be highly vigilant about subarachnoid hemorrhage in patients with sudden headaches, considering these secondary causes can also help avoid misdiagnosis.
signal 2 headache + focal neurological deficits and mental state changes
For patients with headache and new neurological deficits, neuroimaging examinations should be improved immediately without hesitation, including those with mental state changes. Focal neurological defects have high predictive value for patients with intracranial pathological changes. For such patients, the physician should consider malignant tumors, trauma, infection and disease states that lead to elevated intracranial pressure, including the vascular etiology mentioned above. In addition, carbon monoxide poisoning can also lead to neurological defects.
In addition, in acute cerebrovascular disease, although headaches are most common in hemorrhagic stroke or subarachnoid hemorrhage, patients with ischemic stroke can also experience headaches during the onset. In contrast, women, young patients, and patients with circulating ischemic and infarction after are more likely to have headaches when they have ischemic stroke. Therefore, it is necessary to pay attention here to not misdiagnose young female patients with ischemic stroke as hemiplegic migraine.
For patients with unilateral headache, facial pain or neck headache, carotid dissection should be considered in time if anterior circulation symptoms occur, especially if the patient shows sudden retinal ischemia symptoms or Horner syndrome . In addition, the symptoms of the above pain plus postcirculatory stroke should be considered for vertebral artery dissection.
Finally, specific cranial nerve function defects should also be vigilant. Optic nerve paralysis may be caused by cerebral ischemia, temporal artery inflammation or primary eye disease. Among the diseases of ocular motor nerve paralysis and headache, the most important thing to be wary of is the posterior communication aneurysm of subarachnoid . Dissector nerve paralysis may indicate changes in intracranial pressure, and simultaneous involvement of the ocular motor nerve, trochanteral nerve and dissector nerve suggest cavernous sinus lesions.
signal 3 headache + immunosuppressive status
When patients with a history of immunosuppressive medical treatment have headaches, they should immediately think of intracranial lesions. The main factors that need to be considered include infectious causes such as cryptococcal meningitis, toxoplasmosis, , and non-infectious causes such as lymphoma, .More comprehensive management is particularly important for this patient population.
signal 4 headache + elderly patients
For elderly patients, the risk of headache is higher due to secondary causes, including intracranial hemorrhage, hidden intracranial trauma, giant cell arteritis, malignant tumors, etc. The American College of Emergency Physicians recommends advanced imaging examinations for patients over 50 years of age who have new headaches. Giant cell arteritis should be considered for patients over the age of 60, especially with rheumatoid arteritis or such as scalp tenderness, jaw motion disorder (jaw lameness), or visual symptoms.
signal 5 headache + pregnancy
Common causes of headache in pregnant or postpartum patients are similar to those in the general population, such as primary headache, tension headache or migraine , etc., but the risk of secondary headache during pregnancy has increased. Due to the characteristics of pregnancy-related hypercoagulant state and the increase in pituitary volume, the first thing to do is to carefully evaluate the causes of cerebral venous thrombosis and pituitary stroke, and preeclampsia in obstetrics should also be considered.
For postpartum patients, headache after lumbar puncture and reversible cerebrovascular contraction syndrome should also be considered, which is a rare cause of headaches in early postpartum, characterized by acute and severe headache caused by prolonged contraction of the middle cerebral artery.
signal 6 headache + coagulation dysfunction
The possibility of headaches due to secondary causes is also increased in patients with any hypercoagulant or anticoagulant state. On the one hand, genetic or acquired thrombotic diseases can increase the risk of cerebral venous thrombosis, and patients with oral contraceptives and hyperhomocysteinemia also have an increased risk.
. In patients with hemorrhagic diseases, the possibility of spontaneous intracranial hemorrhage will also increase. For example, hemophilia patients have a higher risk of intracranial hemorrhage, especially after trauma. Patients using anticoagulants should also pay special attention. After intracranial hemorrhage, rapid neurological deterioration and hematoma may occur, which further emphasizes the importance of rapid diagnosis and intervention.
signal 7 headache + tumor history
Patients with malignant tumors may cause headaches for a variety of reasons, including the effects of the tumor itself or treatment. Although it is traditionally believed that morning or night headaches suggest intracranial malignancy, this pattern is actually uncommon in adult patients, and accordingly, nausea, vomiting, and neurological abnormalities are more common. Both primary and metastatic tumors may cause headaches, with an overall incidence of about 60%. Common intracranial metastasis include lung cancer, melanoma , kidney cancer , breast cancer , and colorectal cancer. Clinicians should note that brain tumors rarely experience isolated headache symptoms, and most patients will also experience concomitant neurological deficits, neuropsychiatric disorders, or epilepsy episodes.
In addition to headaches caused by the tumor itself, patients with intracranial malignant tumors also have the risk of intracranial hemorrhage. About 1% to 11% of cases of intracranial hemorrhage are secondary to malignant tumors, most commonly in metastatic solid tumors. Therefore, if the tumor patient develops new headaches, the diagnosis should be further clarified. In addition, patients undergoing chemotherapy or radiotherapy and patients undergoing craniotomy surgery may develop new headaches. Before considering headaches caused by treatment, the serious causes of headaches should be ruled out.
signal 8 headache + fever
fever may be caused by central nervous system infection or systemic disease. It is particularly difficult to distinguish central nervous system infection from other systemic causes such as sepsis. If other systemic causes are not obvious, meningitis or meningoencephalitis can be assessed by lumbar puncture, but some patients are at risk of elevated intracranial pressure and should consider improving imaging examinations before lumbar puncture.
Specifically, considering the risk of brain hernia in patients, patients with the following characteristics should consider undergoing CT scans before lumbar puncture: over 60 years old, impaired immunity, history of central nervous system diseases, recent epilepsy attacks, mental state changes, focal neurological defects or optic papillary edema.
Brain abscess is another rare but severe central nervous system infection. About 70% of patients with brain abscesses report headaches, but only 50% of patients develop fever, while only 20% of patients with fever, headaches and focal neurological deficits are present. For patients with risk factors for intracranial infection of , such as neurosurgery, sinusitis or otitis media and other infections, the possibility of brain abscess should be considered.
Other non-infectious causes that cause headaches and fever include subarachnoid hemorrhage, pituitary stroke and giant cell arteritis. Fever in patients with subarachnoid hemorrhage may indicate a poor prognosis. Not only may patients with pituitary stroke have symptoms of meningeal irritation, but cerebrospinal fluid specimens may also show changes similar to meningitis, requiring extra caution. In short, the severity of related diseases of headache and fever varies, and such patients should be carefully and comprehensively evaluated, taking into account primary central nervous system infection and non-infectious causes.
signal 9 headache + visual defect
is crucial to clarify the nature of the patient's visual symptoms, which helps confirm the severity of the disease. For example, patients with migraine may have visual auras, which are mainly manifested as flashes and spots, and are usually relieved within 1 hour. Differentiating these relatively benign visual symptoms from severe visual symptoms can help prevent misdiagnosis and misdiagnosis.
Patients with headache with transient unilateral vision loss should be evaluated for secondary headache. Carotid artery dissection can cause retinal ischemia, but it is relatively rare; other reasons include optic neuritis , giant cell artery artery , and acute angle-closing glaucoma. When the patient experiences vision loss in both eyes, idiopathic intracranial hypertension and intracranial tumors should be especially considered.
In addition, visual field examination should be performed on all patients who complain of headache and visual impairment. Patients with headache have visual field defects and , which strongly suggests the possibility of dangerous causes. Most adult patients with hemibian are secondary to vascular lesions, including intracranial hemorrhage, followed by trauma and brain tumors. Fundus examination is another important assessment method, and the presence of optic papillary edema indicates the cause of increased intracranial pressure, including idiopathic intracranial hypertension, cerebral venous thrombosis, malignant tumors or infections. Patients with headaches and optic papilled edema need to be treated expeditiously to prevent ischemia and permanent optic nerve damage.
signal 10 headache + loss of consciousness
headache with loss of consciousness is a very worrying situation. In some cases, it may be difficult to identify whether a patient has had a syncope or epileptic episode, both of which are justified in further investigation. In the case of headache and loss of consciousness, vascular causes should be mainly considered and eliminated. 5% of patients with subarachnoid hemorrhage may experience syncope, which requires major considerations. Intracranial mass blocking third ventricle may also lead to headaches and fainting.
headache with epilepsy seizures suggest several dangerous situations, including eclampsia , central nervous system infection, intracranial hemorrhage, central nervous system malignancy and increased intracranial pressure. For patients with subarachnoid hemorrhage, the presence of epilepsy alone suggests a poor clinical prognosis. Regardless of the cause of coma, a thorough diagnostic evaluation is required for patients with this type of headache.
Summary of the risk of secondary headache
can refer to the following table for diagnosis.
Yimaitong compiled from: Tabatabai R R, Swadron S P. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes[J]. Emergency Medicine Clinics of North America, 2016, 34(4):695.
