Urgent considerations

See Differentials for more details

About 6% to 10% of patients who present with a headache have a serious pathology.[9][10] The following conditions present particular challenges and require immediate intervention.

Meningitis

  • Presents with fever, headache, stiff neck.

  • Patients may develop meningococcal sepsis, presenting with hypotension, altered mental state, and purpuric or petechial rash.

  • Patients should undergo lumbar puncture (LP) within 1 hour of arrival at hospital, provided it is safe to do so, and commence antibiotic treatment immediately afterwards.[11][12]​​​​​​​ If there is high suspicion, antibiotics should be administered empirically before LP.

  • If LP is delayed for CT, blood cultures should be obtained and broad-spectrum antibiotics given before CT.​​​[11]

Epidural haematoma

  • History of blunt head trauma at temporoparietal aspect of skull

  • Immediate CT

Subdural haematoma

  • History of alcohol misuse, coagulopathy, trauma

  • Immediate CT

Subarachnoid haemorrhage (SAH)

  • Sudden onset, worst headache of life

  • Immediate CT[13]

May present with a 'thunderclap' headache (sudden onset of severe headache) or 'sentinel' headache (a mild headache preceding the severe one, seen in 10% to 43%).[14][15]

Use of the Ottawa subarachnoid hemorrhage rule may reduce the incidence of missed SAH (and need for emergent CT) among patients aged ≥15 years with a normal neurological examination and peak headache severity within 1 hour of symptom onset.​[13][14]​​​[16]​​

The average age at onset is approximately 55 years; SAH is more common in women than men.[17][18]

Hypertensive encephalopathy

  • Elevated BP, mean arterial pressure >150 to 200 mmHg

  • Immediate CT

  • BP should be quickly lowered by 20% to 25% (labetalol, nicardipine)

Eclampsia/pre-eclampsia

  • Elevated BP in pregnant or peripartum patients

  • May have proteinuria, pedal oedema, and seizure

  • Obstetrician-gynaecologist consultation for safe BP lowering and urgent management of pregnancy

Giant cell arteritis

  • Patients aged >50 years, with their first severe headache

  • Erythrocyte sedimentation rate is checked

  • Immediate treatment with corticosteroids is required to prevent blindness if diagnosis is suspected

Acute angle-closure glaucoma

  • Headache in older person (aged >50 years)

  • Decreased visual acuity, nausea/vomiting, eye pain, mid-dilated fixed pupil

  • Intra-ocular pressure should be reduced (pilocarpine, timolol, or acetazolamide)

  • Ophthalmology consultation

Raised intracranial pressure

  • Untreated may lead to permanent sight loss, permanent neurological deficit, and death.

  • Constant, severe headache. May be aggravated by coughing, straining, or bending. One third of patients report a headache that is worse on waking.[19]

  • Patients also experience visual symptoms, including blurred or double vision, and transient losses of vision.

  • Examine fundi for papilloedema.

  • Urgent neuroimaging looking for mass lesion, followed by lumbar puncture if safe.

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