Headaches - When Should I Worry?


If you haven't had a really bad headache in the past year, take comfort: you're an exception, and are very fortunate, indeed. The vast majority of us will experience at least several headaches a year, and fortunately, the overwhelming majority of headaches are benign, and are not indicative of any serious disease. The real question then is what kind of headaches are harbingers of more serious illness, and which headaches should prompt a visit to a local emergency department?
While there are dozens of causes of headaches, the two most common types of headaches are either tension-type headaches of muscular contraction headaches, and migraine headaches.

Tension headaches
are commonly associated with psychosocial stressors, and are characterized by pains in the back of the head and neck, not usually associated with nausea, vomiting, or any visual disturbances. The pain may be described as a tight band or a pressing sensation.

Migraine headaches
are often associated with fleeting visual disturbances preceding the migraines and tend to be one-sided in nature and tend to be a throbbing pain. Migraine headaches may be precipitated by certain foods, lack of sleep, and stress. They are not accompanied by fevers.

What kind of headache should prompt a visit to the emergency department?

There are two life-threatening diseases which cause headaches and must be seen on an urgent basis.
The first is known as a subarachnoid hemorrhage, which results from a brain aneurysm which suddenly leaks, with the resultant leakage of blood into the fluid surrounding the brain.
The pain of this headache is usually severe and sudden, often described as the worst headache ever, and often located in the back of the scalp. If you ever experience a headache that feels like you've just been hit by a hammer on the back of your head, you need to go to an emergency department. While a ruptured aneurysm may be catastrophic at the onset, more often than not, there is just a "warning leak", which if picked up early enough, can allow us to investigate for a possible aneurysm and then repair the aneurysm with neurosurgery.
The other disease that we worry about in the emergency department is meningitis.
As a general rule, meningitis is usually associated with fever, nausea and vomiting. When meningitis is caused by a bacteria, the natural progression of the disease tends to be fairly quick: patients become generally unwell, with fever, vomiting, headache, and becoming progressively more ill over a matter of hours. Neck stiffness and neck pain is a common complaint. Patients who have meningitis because of a virus tend to be less ill and may develop their symptoms over a couple of days. People with viral meningitis may have headaches, vomiting, and a fever as well. The prognosis of people with viral meningitis is much better, and this is often a self-limited disease.

When you should go to an emergency department with a headache?

  1. If the headache has come on suddenly, and is the worst headache you have ever had in your life.
  2. If the headache is associated with any visual complaints, any slurred speech, or any other neurological-type symptoms.
  3. If you have a fever, stiff neck, and/or are feeling generally very unwell.

Author: By Eric Letovsky, MD, CM, MCFP(EM), FRCP(C)
Chief, Department of Emergency Medicine


Credit Valley Hospital