Detecting potentially life-threatening headache syndromes: first rule out ruptured aneurysm or warning leak's sentinel headache

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Date: Jan. 2003
From: The Journal of Critical Illness(Vol. 18, Issue 1)
Publisher: CMP Medica, LLC
Document Type: Article
Length: 4,689 words

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As many as 1 in 3 sudden severe headaches in patients presenting to a general practitioner signifies an urgent or emergent neurologic condition that requires rapid evaluation and treatment. Headaches associated with serious neurologic illness typically have characteristic signs, symptoms, and time courses. Clinicians need to maintain a high degree of awareness for possible subarachnoid hemorrhage, vascular dissections, cerebral sinus thrombosis, intracranial hematomas, brain tumors, and other conditions. Important danger signs include sudden-onset severe headache, vomiting when headache is not attributable to migraine, and failure of conventional therapy to relieve the headache. Other markers of potentially life-threatening underlying disease include worsening of headache over days or weeks; abnormal neurologic findings on examination; onset of severe headache after age 55; and headache precipitated by bending, lifting, or coughing. A headache that disturbs sleep or is present on awakening is also a source of concern. (J Crit Illness. 2003;18(1 ):23-30)


Most patients with headaches have common headache disorders, such as tension headaches, migraines, or cluster headaches. While headache is not the usual manifestation of a brain tumor or stroke, a serious headache can be a sign of underlying neurologic disease. About 10% of headaches evaluated in emergency departments have secondary causes, and approximately 37% of acute headaches in patients presenting to general practitioners can be attributed to serious neurologic conditions. (1)

The relatively small subset of patients with potentially life-threatening headaches represents a group of patients whose diagnoses clinicians simply cannot afford to miss. Two caveats apply. First, a sudden-onset, severe headache often--but not always--is a red flag for a condition that requires rapid evaluation and treatment. Second, while lack of response should not be used as a diagnostic tool, if a seemingly commonplace headache syndrome does not respond to conventional therapy, evaluation for a neurologic problem is appropriate.

In this 2-part series, we will outline practical approaches to diagnosis, including practical tip-offs to early recognition, of 10 potentially serious neurologic disorders that feature headache as a prominent symptom (Tables 1 and 2). This first article will cover subarachnoid hemorrhage (SAH), vascular dissections, cerebral venous sinus thrombosis (CVST), intracranial hematomas, and brain tumors (Table 3). In the second article, to be published in a future issue of The Journal of Critical Illness, we will discuss infections of the CNS, pseudotumor cerebri, temporal arteritis, cavernous sinus lesions, and posterior leukoencephalopathy, as well as the link between headache and stroke and the emergency management of acute open-angle glaucoma. (2-7)


In the United States, SAH affects approximately 15,000 persons annually.(8) The mortality from a ruptured aneurysm approaches 50%, although the rate is 35% or even lower in some recent reports, and approximately one third of the survivors remain dependent.(9) Evidence from the literature suggests that early recognition and intervention improve survival.(10) SAH occurs twice as often in women as it does in men.(11)

Clinical presentation

The presentation varies widely, but SAH typically is heralded by a violent headache of sudden onset that reaches maximum intensity within a few minutes, followed by depression...

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Gale Document Number: GALE|A97113785