When an intense headache strikes

110110.Bobo suffering from a headache.812 Picture: Sizwe Ndingane

110110.Bobo suffering from a headache.812 Picture: Sizwe Ndingane

Published Aug 20, 2014

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QUESTION: I am worried about my risk of having a brain bleed. My brother died at the age of 32 after a sudden, unexpected brain haemorrhage.

He collapsed after a severe headache and got worse over a few hours, then just stopped breathing.

He was fit and never needed any chronic medication. I struggle to understand why this happened to a healthy person who did not even smoke or drink alcohol. He exercised regularly and even ran a few half marathons.

Is this genetic and can I prevent it happening to me?

 

ANSWER: I cannot even imagine what traumatic experience this was for you and his immediate family.

So many people ask me when to seek help from a doctor for headaches. The frequency as well as the intensity and response to treatment usually guides most of us.

The term “thunderclap headache” describes the rapid, acute onset of an intense headache – often likened to being struck by a lightening bolt of pain. It hits you hard, reaching maximum intensity within seconds to minutes of onset.

 

Warning signs

Thunderclap headaches can lead to a number of neurological symptoms. The sequelae would depend on the cause of the headache. The most important ones being:

*

Subarachnoid haemorrhage (SAH): a transient loss of consciousness, seizures, meningism (neck pain and stiffness), visual symptoms, and vomiting can occur.

This is when a bleed occurs on the surface of the brain due to a rupture or leak in one or more blood vessels covered by a membrane which is part of the meninges – the arachnoid membrane which resembles a spider web of blood vessels.

More than 50 percent of people with subarachnoid haemorrhage have an isolated headache, which typically lasts several days, without decreased level of consciousness.

*

Cerebral venous sinus thrombosis: caused by thrombosis of the veins of the brain which leads to a headache due to raised intracranial pressure.

This is aggravated by things like coughing or sneezing which further raise the intracranial pressure.

In less than 10 percent of cases is the onset a thunderclap headache. Most patients will develop accompanying clinical symptoms like weakness of a body part or seizures.

*

Carotid artery dissection and vertebral artery dissection: this refers to a tear which can form on the inside wall of the artery. This often causes pain on the affected side of the head or neck.

If the blood flow to the brain is impaired, this leads to visual symptoms, weakness of part of the body, and other abnormalities depending on the vessel affected and the area of the brain receiving too little oxygen.

 

What should I do?

Rush to your closest emergency room as further investigation is required to identify the cause of the thunderclap headache – aneurisms are often left too long before intervention.

 

Risks

Potentially, you could die. Depending on the cause, as well as the size of a bleed or the duration of impaired blood supply to the brain, a spectrum of damage to the brain occurs.

Pressure in the skull rises, squashing parts of the brain and this leads to herniation.

 

Diagnosis

This is made through Computed Tomography (CT) of the brain, which is sensitive for subarachnoid haemorrhage.

Sometimes a lumbar puncture is performed because a small proportion of subarachnoid haemorrhage is missed on a CT scan. The lumbar puncture is done to exclude the presence of haemolysed red blood cells in the cerebrospinal fluid as xanthochromia – a straw coloured appearance.

 

Cerebral angiography has emerged as a highly specialised skilled procedure – not without risk.

This is a more precise but invasive investigation of the brain’s blood vessels.

 

Complications

Hydrocephalus, vasospasm of the brain arteries (impaired blood flow), seizures and neurocognitive problems can also occur.

 

Prognosis

Subarachnoid haemorrhage is often associated with a poor outcome. The death rate is between 40 and 50 percent. More than a quarter have restrictions in their lifestyle. Delay in diagnosis of minor incidents (mistaking the sudden headache for migraine) contributes to poor outcome.

 

Risk can be a grey matter

* Risk increases with age – 25 percent higher in women over 55 years.

* Genetics: risk is increased up to five-fold in first-degree relatives of sufferers.

* Lifestyle factors: smoking, hypertension and excessive alcohol intake.

* It is well documented that aneurysmal bleeds occur after sexual intercourse.

* 10 percent of people with subarachnoid haemorrhage are bending over or lifting heavy objects at the onset of their symptoms.

 

* Dr Darren Green, a trusted figure in the field of media medicine, is a University of Stellenbosch graduate who adds innovative spark to health and wellness issues.

He features on 567CapeTalk, and is a regular guest on SABC3 and the Expresso show. Dr Green works as an emergency medical practitioner at a leading Cape Town hospital and completed four years of training as a registrar in the specialisation of neurology.

If you’ve got medical problems, contact the doctor at [email protected], 021 930 0655 or Twitter @drdarrengreen. Catch him in Cape Town on 567 CapeTalk, most Fridays at 1.30pm.

The advice in this column does not replace a consultation and clinical evaluation with a doctor.

Cape Argus

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