We’ve already addressed the “worst headache ever” (Acute H/A – 1) and when to suspect masses plus a basic Neuro exam (Acute H/A – 2). On now to other acute headaches NOT TO MISS. Here’s our table from the initial posting. Most of these catastrophic conditions present within a few days of onset.
Headache with Fever
If “Headache” is associated with fever, approach it through the differential diagnosis of “Fever.” However, if the headache is the main significant symptom, consider certain possibilities.
** Meningitis — Bacterial meningitis is not subtle. Patients have severe pain, and are unable to flex their neck. To elicit the latter sign, there’s no need to perform special maneuvers; simply ask the patient to look at their belly button. If unable, it’s meningitis until proven otherwise.
Children with meningitis look toxic. Adults (>99%) have at least 1 of 3 symptoms: fever, stiff neck, or altered mental status. The patient with headache who has none of these won’t have meningitis.
Other pathogens may be more subtle. TB meningitis presents sub-acutely. In Encephalitis, the headache is less prominent than confusion or altered mental status. Viral meningitis can cause prominent headache, but is self-limiting. The headache of a brain abscess is not as severe as meningitis. Patients with cavernous venous thrombosis [e.g. extension of bacterial sinusitis into the CNS] look very ill.
P.S.: If you suspect bacterial meningitis, call 911 to transport to an E.D. by ambulance. Start an IV (meningococcal meningitis decompensates rapidly into shock). If arrival at a hospital E.D. will be delayed, draw a blood culture, perform an LP, & administer penicillin or ceftriaxone, IV or IM. If unable to obtain the labs & there’ll be an hour’s delay, give the antibiotic anyway.
** Rocky Mountain Spotted Fever — Think of RMSF if the patient has been in an endemic area during tick season [April to September]. Where’s the endemic area? North Carolina usually outshines all states in incidence, though Oklahoma won in 2009 & 2010. Other hot spots follow the belt of Tennessee, Arkansas, and Missouri, plus northern counties in Georgia & Alabama. Colorado and Utah invariably rank among the least likely places to contract rickettsia.
RMSF begins with fever & headache. The “spots,” [acral macules that become petichiae & move centrally] don’t begin until the 3rd or 4th day, which may be too late if shock ensues too. Petichiae don’t blanche, except in their first 6-12 hours of appearance!!! Diagnosis of RMSF is clinical; no blood test will help.
In the endemic area and season, clinicians commonly prescribe doxycycline to all patients with fever and headache. Even to children and pregnant women!!! The horrifying specter of tooth staining may be nothing more than an “old doctors’ tale” [see the CDC’s MMWR March 31, 2006 / 55(RR04), especially under “treatment,” pp. 12-13].
** AIDS Infections — Infections like cryptococcal meningitis & cerebral toxoplasmosis occur at severe levels of immunodeficiency (T-cell count usually <150). Most HIV patients know their numbers, but many don’t even know they’re infected. We all know the risk factors to ask about, such as multiple sexual partners [especially receptive anal sex] and injection drug use; past use more so than present if you worry about AIDS today. But also, in the course of a physical exam or chart review, you may come across clinical clues suggesting undiagnosed HIV:
- Shotty lymphadenopathy in atypical locations: axillary, posterior cervical, occipital, & especially epitrochlear.
- Seborrheic dermatitis: extensive upper & central facial scaly erythema (not dandruff).
- Recurrent Staph infections.
- History of zoster at a youngish age (under 50).
Oral stigmata may be especially revealing:
- thrush [on buccal mucosa & palate, not so much the tongue]
- hairy leukoplakia [vertical corrugated white streaks on sides of tongue]
- Kaposi’s sarcoma [ecchymoses on the palate]
- Severe gingivitis
Certain abnormal laboratory tests should raise an index of suspicion:
- thrombocytopenia [platelets <100,000]
- lymphopenia [absolute lymphocyte count <1,000]
- elevated serum globulins [total protein minus the albumin equals >4.0 g/dL]
- very low HDL cholesterol [<25 mg/dL]
A 38 year-old woman, typical immigrant from rural Mexico with husband & child, sought care in San Francisco in 1995 for chronic diarrhea. Got worked-up for every possible bowel disease, infectious & otherwise, to no avail. Frustrated, she returned to Mexico — doctors there heard, “Lady from San Francisco, chronic diarrhea,” & nailed the HIV diagnosis in 5 minutes.
If a patient presents with fever and headache, and you think they have AIDS, or might have undiagnosed HIV, send them to an E.D. for the work-up.
** Temporal Arteritis — This may present with a low-grade fever, or none at all. You can often rule out temporal arteritis by a patient’s birthday; it never occurs younger than 50 years old, and usually over 60. Jaw claudication occurs in 50% of patients: masseter muscles are weak or painful with chewing and excessive talking. Up to 50% of patients may also complain of malaise & early-morning arthralgias of shoulders, hips, or spine. Either or both temporal arteries may feel stiff and hypertrophic, tender, with absent temporal pulse(s), but they may often be normal. An anemia of chronic disease is not unusual.
The catastrophic sequela is blindness, which may occur abruptly. I learned the “Rule of 60”: Headache patient over 60-years-old, with sed rate over 60, gets 60 of prednisone. The sedimentation rate (ESR) is usually higher, even 100 mm/hr. I order it for all patients over 50-years-old with a new headache. Since 10% of patients may have an ESR <50, consult rheumatology if presentation is suggestive; consult rapidly if any visual symptoms are present.
Unfortunately, the steroid course is 2 years, so you really want proof by biopsy. Steroids can be started immediately, but a biopsy should be ideally arranged within 2 weeks. Failure to dramatically improve after a week of steroids suggests an alternative diagnosis.
Afebrile Headaches NOT TO MISS
** Tony-Award-winning actor Natasha Richardson fell on a beginners’ ski slope in rural Quebec, hitting her head. She got up and laughed, refused to seek care because she felt fine. Two hours later a headache developed; four more hours passed before reaching a full-fledged hospital, at which point she may have already been brain-dead from herniation. Sadly, she died.
An epidural hematoma occurs from blunt trauma that ruptures a vessel between the dura and the skull. There may or may not be brief loss of consciousness or a skull fracture. Patients experience a “lucid interval” between injury and onset of headache. Anyone who develops a progressive headache within 24 hours [perhaps even 48 hours] of head trauma requires an immediate non-contrast head CT, which is 100% sensitive.
** A student once related how she sought ER care for a new headache, and was reassured it was just “tension.” She returned later feeling even worse, and was told “go home and relax, honey.” Home happened to be where the faulty heater leaked; fortunately an astute physician assistant made the connection on her third visit, or I might never have heard the story.
Whenever a patient complains of a new headache in winter, or during a car ride, consider possible carbon monoxide (CO) poisoning. Other symptoms may merely be an inability to concentrate. Textbooks mention “cherry-red skin changes”: that’s rare, & end-stage. If two patients from the same environment ever develop simultaneous symptoms, it’s CO poisoning until proven otherwise.
** Hypertension — This is almost never the culprit. The B/P would have to be over 240/140. Lower levels [180/110] might be implicated if headache was severe, or there were also vomiting and bona fide neurological signs or symptoms. It’s also nice to know a baseline; some untreated patients with malignant hypertension walk around asymptomatic with pressures of 240/140 (though they won’t walk around too much longer).
I never mention that hypertension can cause headaches; in fact, I tell patients that it doesn’t. Those who think it can, sometimes reason, “I don’t have a headache, so my pressure must be OK,” and skip their meds.
** Anemia (acute or severe) — Rapid onset of anemia causes a headache due to relative hypoxia. The cardinal symptom of anemia is dyspnea, if not at rest, then certainly with exertion. No dyspnea on exertion means no acute or severe anemia.
** Acute Primary Closed-Angle Glaucoma — This causes “eye pain,” which, if retro-orbital, may mislead the clinician into addressing “headache”. The pain is very acute and severe, with nausea and often vomiting. Diagnosis is made by thinking of the eye: red, perhaps with cloudy cornea and fixed pupil. Treatment is immediate iridotomy.
** Depression — Up to 45% of patients attempting suicide visit their primary provider during the preceding month. Maybe for “headache.” Not that you want to ask everyone who complains of a headache, “And by the way, have you been thinking of killing yourself?”
An imminently-suicidal person may not appear depressed. In fact, having made the decision, they may feel quite at ease, but still want another opinion. This can be hard to detect; I know of no literature describing how such a patient presents. And we see so many patients with “headache,” it’s easy to dismiss the one with a vague history. The best we can do is to be on the alert for a “chief complaint” that doesn’t quite make sense — why, after all, is this person presenting like this today? — then gently inquire if things are going OK.
In terms of such chief complaints, click if you’re up for a horror story.
** AIDS Infections — May occur without fever; see the blurb above.
** Temporal Arteritis — May occur without fever. See the blurb above.