The most common neurologic symptom, headaches may be localized or generalized, producing mild to severe pain. About 90% of all headaches are benign and can be described as vascular, muscle-contraction, or a combination of both. (See Comparing benign headaches.) Occasionally, though, headaches indicate a severe neurologic disorder associated with intracranial inflammation, increased intracranial pressure (ICP), or meningeal irritation. They may also result from an ocular or sinus disorder, tests, drugs, or other treatments.
Other causes of headache include fever, eyestrain, dehydration, and systemic febrile illnesses. Headaches may occur in certain metabolic disturbances—such as hypoxemia, hypercapnia, hyperglycemia, and hypoglycemia—but they aren't a diagnostic or prominent symptom in these disorders. Some individuals get headaches after seizures or from coughing, sneezing, heavy lifting, or stooping.
♦ Anthrax, cutaneous. Along with a macular or papular lesion that develops into a vesicle and finally a painless ulcer, this disorder may produce a headache, lymphadenopathy, fever, and malaise.
♦ Brain abscess.
In this disorder, the headache is localized to the abscess site; it usually intensifies over a few days and is aggravated by straining. Accompanying the headache may be nausea, vomiting, and focal or generalized seizures. The patient's LOC varies from drowsiness to deep stupor. Depending on the abscess site, associated signs and symptoms may include aphasia, impaired visual acuity, hemiparesis, ataxia, tremors, and personality changes. Signs of infection, such as fever and pallor, usually develop late; however, if the
abscess remains encapsulated, these signs may not appear.
♦ Brain tumor.
Initially, a tumor causes a localized headache near the tumor site; as the tumor grows, the headache eventually becomes generalized. The pain is usually intermittent, deep seated, and dull and is most intense in the morning. It's aggravated by coughing, stooping, Valsalva's maneuver, and changes in head position, and it's relieved by sitting and rest.
Associated signs and symptoms include personality changes, altered LOC, motor and sensory dysfunction, and eventually signs of increased ICP, such as vomiting, increased systolic blood pressure, and widened pulse pressure.
♦ Cerebral aneurysm (ruptured).
Cerebral aneurysm is a life-threatening disorder that's characterized by a sudden excruciating headache, which may be unilateral and usually peaks within minutes of the rupture. The patient
may lose consciousness immediately or display a variably altered LOC. Depending on the severity and location of the bleeding, he may also exhibit nausea and vomiting; signs and symptoms of meningeal irritation, such as nuchal rigidity and blurred vision; hemiparesis; and other features.
♦ Ebola virus. A sudden headache commonly occurs on the 5th day of this deadly illness. Additionally, the patient has a history of malaise, myalgia, high fever, diarrhea, abdominal pain, dehydration, and lethargy. A maculopapular rash develops between the 5th and 7th days of the illness. Other possible findings include pleuritic chest pain; a dry, hacking cough; pronounced pharyngitis; hematemesis; melena; and bleeding from the nose, gums, and vagina. Death usually occurs in the 2nd week of the illness, preceded by massive blood loss and shock.
♦ Encephalitis. A severe, generalized headache is characteristic with this disorder. Within 48 hours, the patient's LOC typically deteriorates —perhaps from lethargy to coma. Associated signs and symptoms include fever, nuchal rigidity, irritability, seizures, nausea and vomiting, photophobia, cranial nerve palsies such as ptosis, and focal neurologic deficits, such as hemiparesis and hemiplegia.
♦ Epidural hemorrhage (acute). Head trauma and a sudden, brief loss of consciousness usually precede this hemorrhage, which causes a progressively severe headache that's accompanied by nausea and vomiting, bladder distention, confusion, and then a rapid decrease in LOC. Other signs and symptoms include unilateral seizures, hemiparesis, hemiplegia, high fever, decreased pulse rate and bounding pulse, widened pulse pressure, increased blood pressure, a positive Babinski's reflex, and decerebrate posture.
If the patient slips into a coma, his respirations deepen and become stertorous, then shallow and irregular, and eventually cease. Pupil dilation may occur on the same side as the hemorrhage.
♦ Glaucoma, acute angle-closure. This type of glaucoma is an ophthalmic emergency that may cause an excruciating headache as well as acute eye pain, blurred vision, halo vision, nausea, and vomiting. Assessment reveals conjunctival injection, a cloudy cornea, and a moderately dilated, fixed pupil.
♦ Hantavirus pulmonary syndrome. Noncardiogenic pulmonary edema distinguishes this viral disease, which was first reported in the United States in 1993. Common reasons for seeking treatment include flulike signs and symptoms—headache, myalgia, fever, nausea, vomiting, and a cough—followed by respiratory distress. Fever, hypoxia, and (in some patients) serious hypotension typify the hospital course. Other signs and symptoms include a rising respiratory rate (28 breaths/minute or more) and an increased heart rate (120 beats/minute or more).
♦ Hypertension. This disorder may cause a slightly throbbing occipital headache on awakening that decreases in severity during the day. However, if the patient's diastolic blood pressure exceeds 120 mm Hg, the headache remains constant. Associated signs and symptoms include an atrial gallop, restlessness, confusion, nausea and vomiting, blurred vision, seizures, and altered LOC.
♦ Influenza. A severe generalized or frontal headache usually begins suddenly with the flu. Accompanying signs and symptoms may last for 3 to 5 days and include stabbing retro-orbital pain, weakness, diffuse myalgia, fever, chills, coughing, rhinorrhea and, occasionally, hoarseness.
♦ Influenza type A H1N1 virus (swine flu). Influenza type A H1N1, or swine flu, is a respiratory disease of pigs caused by type A influenza virus. Swine flu viruses cause high levels of illness and low death rates in pigs. Swine flu viruses normally don't infect humans; however, sporadic human infections with swine flu have occurred. Most commonly, these cases occur in persons with direct exposure to pigs. The virus has changed slightly and is known as H1N1 flu. Recent outbreaks of H1N1 flu have shown that the virus can be transmitted from person to person, causing transmission across the globe. The H1N1 flu is similar to influenza, and causes illness and in some cases death. The symptoms of swine flu include headache, nonproductive cough, fatigue, myalgia, chills, fever, and vomiting. The use of antiviral drugs is recommended to treat H1N1 flu.
♦ Intracerebral hemorrhage.
In some patients, this hemorrhage produces a severe generalized headache. Other signs and symptoms vary with the size and location of the hemorrhage. A large hemorrhage may produce a rapid, steady decrease in LOC, perhaps resulting in a coma. Other common findings include hemiplegia, hemiparesis, abnormal pupil size and response, aphasia, dizziness, nausea,
vomiting, seizures, decreased sensation, irregular respirations, positive Babinski's reflex, decorticate or decerebrate posture, and increased blood pressure.
♦ Listeriosis. If this infection spreads to the nervous system, it may cause meningitis, whose signs and symptoms include headache, nuchal rigidity, fever, and change in LOC. Earlier signs and symptoms of listeriosis include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea.
Listeriosis during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.
♦ Meningitis. This disorder is marked by the sudden onset of a severe, constant, generalized headache that worsens with movement. Fever and chills are other early signs. As meningitis progresses, it also causes nuchal rigidity, positive Kernig's and Brudzinski's signs, hyperreflexia, altered LOC, seizures, ocular palsies, facial weakness, hearing loss, vomiting and, possibly, opisthotonos and papilledema.
♦ Plague. The pneumonic form of this lethal bacterial infection causes a sudden onset of headache, chills, fever, and myalgia. Pulmonary findings include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, respiratory distress, and cardiopulmonary insufficiency.
♦ Postconcussion syndrome. A generalized or localized headache may develop 1 to 30 days after head trauma and last for 2 to 3 weeks. This characteristic symptom may be described as an aching, pounding, pressing, stabbing, or throbbing pain. The patient's neurologic examination is normal, but he may experience giddiness or dizziness, blurred vision, fatigue, insomnia, inability to concentrate, and noise and alcohol intolerance.
♦ Q fever. Signs and symptoms of this disease include severe headaches, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.
♦ Severe acute respiratory syndrome (SARS). SARS is an acute infectious disease caused by a coronavirus. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. After an incubation period of 2 to 7 days, the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a nonproductive cough, and dyspnea. SARS may produce only mild symptoms, or it may progress to pneumonia and, in some cases, even respiratory failure and death.
♦ Sinusitis (acute). This disorder is usually marked by a dull periorbital headache that's usually aggravated by bending over or touching the face and is relieved by sinus drainage. Fever, sinus tenderness, nasal turbinate edema, sore throat, malaise, cough, and nasal discharge may accompany the headache.
♦ Smallpox (variola major). Initial signs and symptoms of this virus include a severe headache, backache, abdominal pain, high fever, malaise, prostration, and a maculopapular rash on the mucosa of the mouth, pharynx, face, and forearms and then on the trunk and legs. The rash becomes vesicular, then pustular. After 8 or 9 days, the pustules form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.
♦ Subarachnoid hemorrhage. This hemorrhage commonly produces a sudden, violent headache along with nuchal rigidity, nausea and vomiting, seizures, dizziness, ipsilateral pupil dilation, and altered LOC that may rapidly progress to coma. The patient also exhibits positive Kernig's and Brudzinski's signs, photophobia, blurred vision and, possibly, a fever. Focal signs and symptoms (such as hemiparesis, hemiplegia, sensory or vision disturbances, and aphasia) and signs of elevated ICP (such as bradycardia and increased blood pressure) may also occur.
♦ Subdural hematoma. Typically associated with head trauma, both acute and chronic subdural hematomas may cause headache and decreased LOC. An acute subdural hematoma also produces drowsiness, confusion, and agitation that may progress to coma. Later findings include signs of increased ICP and focal neurologic deficits such as hemiparesis.
A chronic subdural hematoma produces a dull, pounding headache that fluctuates in severity and is located over the hematoma. Weeks or months after the initial head trauma, the patient may experience giddiness, personality changes, confusion, seizures, and progressively worsening LOC. Late signs may include unilateral pupil dilation, sluggish pupil reaction to light, and ptosis.
♦ Temporal arteritis.
A throbbing unilateral headache in the temporal or frontotemporal region may be accompanied by vision loss, hearing loss, confusion, and fever. The temporal
arteries are tender, swollen, nodular, and sometimes erythematous.
♦ Tularemia. Signs and symptoms following inhalation of the bacterium Francisella tularensis include abrupt onset of headache, fever, chills, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
♦ Typhus. In typhus, initial symptoms of headache, myalgia, arthralgia, and malaise are followed by an abrupt onset of chills, fever, nausea, and vomiting. A maculopapular rash may also occur.
♦ West Nile encephalitis. This brain infection is caused by West Nile virus, a mosquito-borne flavivirus commonly found in Africa, West Asia, the Middle East and, rarely, in North America. Most patients have mild signs and symptoms, including fever, headache, body aches, rash, and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, and paralysis.