Not another headache!

Here is another of our EM residents - Gayathi Nadarajan
She discusses 3 cases of non-traumatic headaches and their diagnoses with a focus on the evaluation of a patient with acute headache in the ED

Case 1:

A 19-year-old Chinese lady with a background of haemolytic anemia presented in the middle of the night with a 3-day history of the worst headache of her life with neck stiffness. On examination, besides profound neck stiffness, there were no other neurological findings.


CT scan: Acute subarachnoid hemorrhage in the left frontal lobe and acute subdural hemorrhage over the left frontal temporal convexity. Midline shift of 4mm to the right.

4 vessel angiogram : There were no aneurysm

Platelets: normal

All investigations were not completed as patient discharged against advice. Hence no cause was found for her non-traumatic bleed.


Case 2

33-year-old Malay lady with no medical problems as such, presented to the ED with a sudden onset, thunderclap headache, associated with vomiting, left ankle weakness and foot drop. She also noted bruising over her left ring finger tip a few days ago.

Examination revealed a left foot drop and weak ankle inversion with sensory deficit over the dorsum of the foot.

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CT brain: Basal cisterns & pre-pontine SAH, small ICH, superior cerebellar arachnoid cyst & earl communicating hydrocephalus.

CT angiogram: 3mm aneurysm at epicenter of left PCA branch

4 vessel angiogram: Possible mycotic aneurysm of P4 segmental branch of left posterior cerebral artery likely septic emboli or seeding from IE.

Unsuccessful in coiling the aneurysm

She than had craniotomy and excision of the aneurysm.

Transthoracic echocardiogram: bileaflet MVP with severe MR and IE 1.4cmx1.0cm anterior leaflet and 0.5cm posterior leaflet vegetation

Hence a diagnosis of mycotic aneurysm from infective endocarditis was made.


Case 3

A 66-year-old independent and active Chinese gentleman presented to the emergency department as his blood pressure was noted to be high. He has hypertension and hyperlipidemia He routinely measures his blood pressure once a day and yesterday it was as high as 172/70 after measuring for about 3 times. His children than convinced him to come to the ED for a ‘check-up’ as they were worried about the high blood pressure.

He also had a headache for the past 3 days, which was resolving. It wasn’t the worse pain he ever felt but it was the first time he had such a headache. There were no associated or aggravating symptoms with the headache.

On examination, he was very well and had no neurological deficit. His blood pressure at triage was in fact 149/73.

In view of the new onset of headache in his age group, a CT head was ordered.


CT brain: Hyperdense enlargement of the left transverse and sigmoid venous sinuses suspicious for venous sinus thrombosis, complicated by an area of venous infarction & haemorrhage in left parietal lobe

MRI venous: Cerebral venous thrombosis involving the entire left transverse and sigmoid sinuses extending to the proximal internal jugular vein. There is involvement of the left superior and inferior petrosal sinuses and secondary left temporoparietal venous infarction with haemorrhage.

No identifiable cause on MRI.

Patient was diagnosd with cerebral venous thrombosis. He was investigated and started on anticoagulant.



Don’t worry… you are not alone….

While in the consult room, it is normal to have the sinking feeling at the bottom of our stomachs when you are faced with yet another patient with a headache. We know that the headache consult will be a long one indeed. A thorough history taking and examination is crucial to avoid missing an intracerebral bleed.

Headache red flags

For the first 2 cases, the severe, thunderclap headache was a red flag. However, for the 3rd case, it was not obvious as the triage complain was ‘high blood pressure’. But his pressure at triage was fine!

The red flag only came out from ‘digging out’ the history from him. He said “By the way doctor… I did have this headache for the pass 3 days… it actually is getting better. The severity was probably the worst when I measured my blood pressure yesterday. I don’t normally suffer from headaches, but neither would I say this is the worse pain I ever felt!” The red flag was the new onset of headache in a patient above the age of 40

Discussion and more algortithms!!!

The aim of these cases is to:
  • Re-emphasise the value of good history taking in order to avoid missing out a deadly diagnosis such as a intracerebral bleed
  • To revisit red flags that may suggest a bleed
  • Despite the triage complain, ALWAYS ask the patient why they turned up in the ED on that particular day and at that particular time
I will end off with some algorithms, to remind us of headache red flags.

The following from Up To Date is a flowchart on how to approach a patient with headache in the emergency department.




  • Perry, Jeffrey J., et al. "An international study of emergency physicians' practice for acute headache management and the need for a clinical decision rule." CJEM06 (2009): 516-522.
  • Perry, Jeffrey J., et al. "High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study." Bmj 341 (2010): c5204.
  • Perry, Jeffrey J., et al. "Clinical decision rules to rule out subarachnoid hemorrhage for acute headache." Jama12 (2013): 1248-1255.
  • Godwin SA, Villa J. “Acute headache in the ED: Evidence-Based Evaluation and Treatment Options.” Emerg Med Pract 2001; 3(6): 1-32.
  • Newman-Toker, David E., and Jonathan A. Edlow. "High-stakes diagnostic decision rules for serious disorders: the Ottawa subarachnoid hemorrhage rule." JAMA12 (2013): 1237-1239.

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