Now, I would like to discuss a topic and symptom that is very relevant to my practice – headache. I am trained as a neurologist, and I see a lot of patients with headaches of various types, which they run the whole gamut of causes – from simple tension headaches and migraines to life-threatening aneurysms and hemorrhages. There is a system for headache evaluation, and the right questions will help you determine if it is a medical emergency.
I also suffer from tension headaches, especially after an overnight call at the hospital, and I can empathize with everyone who lives with headaches. I do not want to sound like I am reducing the pain and discomfort felt by people suffering from these conditions. Some headaches feel awful, and make you want to crawl into a quiet, dark room, and pretend to be a corpse. But I want this article to focus on those causes of headaches that CAN actually kill you.
But, before we start our discussion, I would like to present this disclaimer. The information in this article is for educational purposes only. I am giving you general medical symptoms and classic cases for your understanding. This is not for diagnosis, and certainly not for treatment. If you are suffering, or even if you may be suffering from any of these conditions, you MUST SEEK PROMPT MEDICAL ATTENTION. It is up to you, however, to act on this information. I want to impress on you the severity of these signs, and educate you as to some of the conditions that they might represent. But after reading about some of the diseases, I hope that you will at least call a medical professional to explain your symptoms and get more information and instructions. And if any doubt enters your mind, and you are worried about you or your loved one’s health and well-being, please go to the emergency room for further evaluation. In life, and especially in medicine, it is always better to be safe than sorry.
Now, headaches are an interesting symptom. Everyone experiences the feeling differently, and describes it in different ways. But there are several common threads, and even description types that you need to understand and look for, that can clue you in to the type of headache. The first, and perhaps one of the most important, is the new onset of a headache, especially in an adult. New headaches are always a concern, and need to be fully worked up in order to exclude dangerous conditions. And even if you already suffer from headaches, any new type of headache needs to be re-evaluated, to make sure that it isn’t something of concern. Even someone who is diagnosed with migraines can still develop a bleed or clot in the brain.
The second diagnostic quality of any headache is the setting when it started. Were you lying in bed, doing nothing, or straining to roll that wet, heavy round bale (even though you know you should have waited for help, or got the tractor)? Did it start after you got hit in the head by something (an errant piece of metal that fell off the wall, or someone accidentally clocked you with a 2×4, or you ran into the wall fan – again!)? These are important pieces of information, and can go a long way in sorting out the most likely mechanism and subsequent treatment.
Associated symptoms are another very important feature. Do you have any upset stomach, nausea, or vomiting? Do you feel lightheaded or dizzy? Is there any blurring of your vision, double vision, or flashing lights? Do you notice any ringing in your ears? How about weakness or numbness in any part of your body? Is there any neck pain? Does the headache worsen if you touch a particular part of your scalp? Does it get better if you turn your head? All of these symptoms help to suggest where the headache might be originating from, for example, inside the skull, in the face, in the muscles and skin of the scalp, or even muscle tension transmitted up from the neck! The answers to these questions all provide very important information and can help you start to figure out some of the likely causes of the headache.
One final word of caution in regards to headache. Unless you are absolutely sure that it is your typical presentation, there is no history of head trauma (you didn’t hit your head or something else didn’t hit it, like that inadvertent hammer swing), and you are an adult (children, especially ones with fever, are at increased risk of a serious medical complication), you should also avoid taking aspirin. Some causes of headaches, which are described below, are the result of bleeding in the skull, and taking aspirin could increase the amount of blood, and make it harder to stop the bleeding.
Now let’s get into a couple of the main diagnoses for concerning headaches that should be evaluated medically. The first one I would like to mention is complex migraine. Most people are familiar with typical, or classical, migraines. Classical migraines usually involve a prodrome or aura – which is something that proceeds the headache, like flashing lights or other visual changes, nausea with or without vomiting – then the headache itself. The headache is usually described as pounding or pulsating, involving one side of the head, and is accompanied by an aversion to lights or sounds. Complex migraines also include many of these features, but can have several other components, like numbness, tingling, weakness, trouble speaking, and complete vision loss. The concern with this constellation of symptoms is that someone might be having a stroke. And while the sensation changes and weakness associated with a migraine are usually (but not always) reversible, those arising from a stroke are not. If you ever suffer any of these symptoms, even in the setting of a headache, please go to your emergency room to be evaluated. People with complex migraines that have stroke-like symptoms should also avoid headache therapies such as imitrex, maxalt, relpax, treximet and other triptan drugs, because these chemicals act by constricting blood vessels, and have the theoretical risk of causing a stroke in the setting of the migraine. In the hospital, you will probably be worked up to rule out a stroke, and then monitored for a day or two to make sure you are okay and that you do not have any recurrent symptoms.
Subarachnoid hemorrhage is another very serious cause of headache, with sudden onset and severe symptoms. In this condition, blood leaks from a damaged blood vessel into the space between the brain itself and an overlying membrane, the arachnoid mater. It can occur after head trauma, but can also happen suddenly, without any injury. For instance, there is a certain subset of people who have weaknesses in the arteries in the brain that can out-pouch, and then rupture. The pain associated with a subarachnoid hemorrhage is described as a “thunderclap” or “the worst headache of [my] life,” because the blood irritates the pain fibers in the arachnoid mater directly. People can also have numbness, weakness and other stroke-like symptoms, as well as confusion, decreased level of consciousness (having trouble staying awake and alert), and even seizures, if the blood irritates the brain tissue too much.
This condition is a medical emergency, and you need immediate medical attention. Please call 911 for the EMS to take you to the ER. Once there, you should have a CAT scan of the head, which is a really good test for detecting blood in the brain. You might also have a spinal tap (lumbar puncture) to look at the fluid that bathes the brain, in order to see if there is any blood there also. You should be admitted to the hospital, and the neurosurgeons will probably be involved in your care, because they have to check and see if there is any defect in the blood vessel wall that they can repair, as well as any additional ones, in order to keep this from recurring. Just know that this is one of the reasons that new headaches are taken so seriously, and why you need a full, somewhat invasive work-up – to avoid worse outcomes.
Another condition where bleeding can cause headache is a subdural hematoma. In this case, however, the blood is trapped between two membrane layers in the skull – the arachnoid and the one near the skull itself (the dura mater). In this envelope, the blood slowly leaks and builds up pressure. This type of bleeding comes from the tearing of bridging veins that drain blood from the brain to large collecting vessels called venous sinuses. These vessels are usually torn in head trauma, which can be mild. The elderly and people who suffer from chronic alcohol abuse are especially prone to this condition, because their brains have degenerated somewhat over time, leaving more room for movement within the skull, and greater chance for the veins to be damaged by that motion. However, spontaneous subdural bleeds can occur in patients who are taken medicines like warfarin or coumadin, or who have chronic liver failure – both of which cause underlying abnormalities in blood clotting.
Anyone who is thought to have suffered from a subdural hematoma should be taken to a hospital. Classically, the headache is dull and can be confused with the head injury that caused the bleed (for example, if someone falls and hits the back of his or her head on the pavement, and has pain there also). But as the blood pools, it puts pressure on the brain, which affects its function, and can result in confusion, agitation or drowsiness, or even difficulty rousing the person. It can also cause weakness and numbness on the opposite side of the body or face, also due to the pressure. The work-up for a subdural is similar to that for a subarachnoid hemorrhage, with the head CAT scan showing the blood. Treatment depends on the size and acuity of the bleed. Medicines that thin the blood are stopped, and if the bleed is small, the patient can be watched. If there is a lot of blood, it may need to be drained surgically.
In addition to bleeding in the skull, blood clots can also cause headaches. Venous sinus thrombosis, for example, is a clot in the venous system, or drainage vessels of the brain. It can cause similar symptoms to a subdural hematoma. The headache produced by a sinus thrombosis is very non-specific, and may not even be in the same location as the clot. People who are predisposed to this condition are ones who suffer from abnormalities of blood coagulation: classically in pregnancy, women who are taking birth control pills and smoking, and rare autoimmune diseases. This condition is one of the reasons why any new headache of sudden onset should be evaluated. It is usually diagnosed by either a CAT scan with IV dye given, or an MRI study of the brain. Treatment is with blood thinners under the close supervision of a doctor, usually a vascular neurologist.
Another type of disease that causes a more localized headache is temporal arteritis. In this disease, there is inflammation and pain in the temple area of the scalp, because of an autoimmune process attacking the temporal artery. It is seen in elderly people, mostly over the age of 50, and can be associated with other types of inflammatory diseases, like some forms of arthritis. The major concern is visual changes, because the same inflammation that affects the temporal artery can also irreversibly damage the artery that supplies blood to the retina, leading to blindness. That is why any headache that is associated with visual changes needs to be taken very seriously and evaluated immediately! In order to diagnosis temporal arteritis, doctors will need to take blood to see if you have elevated markers of inflammation. They should also do an ophthalmoscopic exam (hopefully a formal exam is done by an ophthalmologist who will dilate your pupils and take a detailed look with specialized equipment), in order to look at the back of the retina and see if there are any concerning changes. If presumptive temporal arteritis is diagnosed, you should be started on steroid medicine like prednisone, in order to quiet done the immune system, and reduce further damage to the blood vessel. A definitive diagnosis may require a surgeon to take a small biopsy of the temporal artery (usually a quick outpatient procedure), but that may take several days to schedule and complete.
Now, I have one final condition that causes headaches, and needs urgent evaluation and treatment. It is known as idiopathic intracranial hypertension, or pseudotumor cerebri, because it produces symptoms that are reminiscent of a brain tumor. However, this disease is not related to cancer. It is actually a result of increased production, and associated pressure, of cerebrospinal fluid (CSF), which is continuously produced in the brain and usually reabsorbed as quickly. People who are at-risk for this disease are overweight women, smokers, and people who are taking steroids, birth control pills or high-dose vitamin A (such as for acne). The classic headache presentation is a dull, constant ache over the entire scalp. In addition, people have changes in their vision, in either one or both eye, which can range from blurriness to total blindness. As I mentioned earlier, any headache that includes vision changes is something VERY dangerous until proven otherwise. It needs to be evaluated by a medical professional. Please, PLEASE do not dismiss it out of hand. The concern is that, if left untreated, the visual problems could become permanent. The initial work-up includes an ophthalmoscopic exam and head CAT scan. In addition, once the head CAT scan is complete, a lumbar puncture (spinal tap) should be performed to check cerebrospinal fluid (CSF) pressure. Treatment includes weight reduction, smoking cessation, discontinuing any offending medicines, and potentially starting medicines to help lower CSF production, such as diuretics (water pills). If these medical treatments are not successful, then neurosurgery might have to become involved to place a lumbar drain, which will shunt the CSF away from the brain and help permanently lower the pressure.
Whew! Now that’s a long, concerning list. But I feel that knowledge is important, and powerful, especially when it comes to diseases and symptoms. The more you know about yourself, and what aches, pains, or other changes to take note of, the more you are likely to seek medical attention when needed, and avoid long-term and potentially devastating consequences. But the important point is to act on this information. Headaches can be much more than a nuisance, especially if you are not a typical headache sufferer, or the symptoms are different from your usual headache. Knowing yourself and observing for changes are key. Being fortunate to live in the country, we are blessed with the opportunity to observe many unique, beautiful, and subtle signs in nature. But we also must remember to recognize signs and changes in our own health, and, more importantly, to react appropriately.