What's Your Diagnosis?

Uncovering The Source of a Headache Following a Fall

Badar Zaheer, MD
Zaki Zaheer, DO

  • Answer: E. Subdural hematoma

    Ethanol intoxication was suspected as the primary cause of his behavior and headache. However, due to his fall and altered mental status, the team determined a head CT without contrast was indicated to rule out intracranial hemorrhage. With positive imaging, the diagnosis of subdural hematoma (SDH) was determined.

    SDH are the most common cause of intracranial mass lesions, and chronic alcohol use increases the risk factor of development. When intracranial hemorrhage is suspected, most if not all types of intracranial hemorrhages may be on the differential diagnosis, particularly when considering the patient’s mechanism of injury, clinical findings, and patient age/history. The clinical features that may help differentiate between epidural, subdural, and subarachnoid hemorrhage are the lucid interval, progressively worsening headache, and thunderclap headache, respectively. The lucid interval describes a period where the patient regains consciousness and may have limited symptomatology. However, these patients will present with neurological symptoms after some time and begin to rapidly deteriorate. A CT of an epidural hematoma has the characteristic finding of an elliptical/lens shape hyperdensity that does not pass the suture lines.

    A progressively worsening headache in conjunction with head trauma may be the presenting symptom of an SDH. The CT finding can be described as a crescent hyperdensity that may pass suture lines. This is also the only intracranial hemorrhage out of the three that has been seen to have an increased risk in alcoholics. 

    Finally, a thunderclap headache, or the worst of their life, is characteristic of a subarachnoid hemorrhage. On CT, a star-shaped hyperdensity will be seen.

    In this patient with evidence of heavy alcohol use, head trauma, and a headache lacking descriptors, it is prudent to have all types of intracranial hemorrhage on the differential. With the CT finding of “a hyperdense crescent along the convexity of the brain extending into adjacent cranial compartments,” we can rule out all but SDH. 

    Treatment and management. A call to the nearest tertiary care facility was activated and the patient was transferred to neurosurgery for surgical intervention. A craniotomy was performed, and the subdural hematoma was carefully evacuated.

    Outcome and follow-Up. The patient was transferred, required surgical intervention, and ultimately recovered without any neurological deficits or consequences. The patient was admitted for a three-day observation period. The patient’s previous aphasic symptoms resolved, and the repeat head CT showed a resolution of the subdural hematoma. On day three he was discharged home with plans for follow-up with his primary care physician.

    Discussion. Headache is a very common presentation in the ED, comprising anywhere from 2-3% of ED visits each year,1,2 which accounted for 5 million ED visits in 2011.3 When evaluating headache, it is helpful to group etiologies into two categories. Primary headaches include migraine, cluster headache, and tension headache, all of which are not life threatening.4 On the other hand, secondary headaches often result from life threatening etiologies such as intracranial hemorrhage, cerebral venous thrombosis, carotid or vertebral artery dissection, meningitis, encephalitis, and intracranial mass, amongst others.4–8 Luckily, for patients’ sake, 95-98% of headaches prompting an ED presentation are of primary origin.6,9 Despite the rarity of secondary headaches, evaluation of a patient with headache in the ED must always begin with ruling out of secondary causes due to the rapidly evolving and life-threatening nature of such presentations.

    A thorough history and physical examination is critical to accurately determining whether a patient requires further workup for secondary headache or treatment for primary headache. There are red flag signs in a patient’s history and physical examination that should raise the clinician’s suspicion for secondary headache such as sudden onset, maximal severity at onset, progressive worsening, worsening of severity when laying down, fever, syncope, focal neurological deficit, seizure, immunocompromised state, cancer history, change in mental status, personality change, papilledema, and neck stiffness.6–8,10 Diagnostic evaluation must be tailored to each patient’s specific presentation based on the differential diagnosis. Typical modalities used include noncontrast CT, MRI, and lumbar puncture with CSF analysis.

    The presented case illustrates that clinicians should not default to explaining away potential symptoms by attributing to the patient’s personal traits, personality, lifestyle, or intoxication. What turned out to be altered mental status could have very easily been attributed to the patient’s inebriation. However, as the patient was intoxicated and was brought in due to a fall, altered mental status should be appreciated as a sign of potential pathology rather than behavior. With this clinical understanding, the possibility of an acute brain injury must be considered. In cases of alcohol abuse, several studies have shown that patients are at greater risk of subdural hematomas. Ethanol abuse can lead to higher-risk activities that may result in a fall or a motor vehicle accident. In addition, pre-injury alcohol abuse has been correlated with more severe adverse outcomes in patients who develop SDH.11

    With the prompt ordering of a non-contrast head CT, the SDH was collected, and a timely referral to neurosurgery was made. Had head imaging not been performed, the patient may have been discharged, only to be found obtunded later as the subdural fluid continued to collect.

    Conclusion. When treating patients with headaches, it is crucial to differentiate between primary and secondary causes. In this case, an intoxicated patient with behavioral changes had a limited ability to elicit a full history. In the setting of head trauma, a change in mood or personality should not be explained away by recent alcohol or other substance abuse. Concurrent substance abuse necessitates a detailed and systematic process to rule out all other possible causes that could be masked.

    AUTHORS:
    Badar Zaheer, MD1 • Zaki Zaheer, DO 2

    AFFILIATIONS:
    1Associate Professor, Department of Family Medicine, University of Illinois at Chicago & Emergency Medicine Physician 
    2Department of Radiology Resident Physician, Franciscan Health Olympia Fields

    CITATION:
    Zaheer B, Zaheer Z. Uncovering the source: a case of a headache. Consultant. Published online February 3, 2025.. doi:XX

    Received September 20, 2024. Accepted October 22, 2024.

    DISCLOSURES:
    The authors report no relevant financial relationships.

    ACKNOWLEDGEMENTS:
    The authors would like to acknowledge Teresa Molina Neves, MS for her assistance with reviewing and submitting this manuscript.

    CORRESPONDENCE:
    Badar Zaheer, MD 1919 West Taylor Street, Room 196, Chicago, Illinois 60612 (drbmzaheer@gmail.com)

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