A 26-year-old woman with congenital heart disease came to the emergency department at the Hospital of the University of Pennsylvania, complaining of a severe headache. She said that her headache had gradually worsened over the last two weeks, since she had a tooth extracted.

She also said her neck was stiff.

"Only sleep can resolve my daily headaches," she said, weeping in frustration and pain.

She had no fever, nor any trouble swallowing. We checked to see whether she had any difficulty smiling or speaking, which might  suggest a possible stroke, but no problems there, either. We checked her ability to move her head in all directions plus changes in her mental status, which might have suggested an infection in the brain or spinal cord. She was fine.

Her teeth, gums and mouth appeared normal, though she said that her cheeks felt tender.

At her age, a brain tumor was unlikely. And she hadn't suffered a blow to the head, so bleeding into her brain was unlikely, as well.

Her symptoms seemed to suggest a migraine headache. We gave her medicine for the pain, and ordered advanced head imaging to rule out possible infection from her dental procedure, given the pain in her face.

What we discovered next was entirely unexpected.


A CT scan of the young woman's head revealed a scary finding: Blood was pooling into her brain, compressing her brain against her skull. No wonder she had headaches. The final diagnosis: subdural hematoma.

Head trauma is the usual cause of such bleeding, and because she hadn't suffered a blow to the head, we hadn't considered a hematoma.

But in this woman's case, her underlying heart disease contributed to spontaneous bleeding in multiple parts of her brain. With sub-optimal heart function, the body often compensates by raising systemic blood pressure in other organ systems  — including the brain — that can lead to increased risk of spontaneous hemorrhage.

Another factor that made this an unlikely diagnosis was the patient's age. Chronic subdural hematomas are on the rise – among older patients. Indeed, according to a study published in the Journal of Neurosurgery, it is expected to be the most common cranial neurosurgical condition among adults by the year 2030.

Headaches are common, but finding their cause can be difficult. Because headaches can point to a number of diagnoses, they have been called "the great masquerader."

So it can be especially hard for a patient to decide whether a headache warrants a medical evaluation. As unusual as our patient's case was, it is a prime example of why we always look for dangerous "red-flag" signs and symptoms whenever a patient in the emergency room complains of headaches. This young woman had a few red flags, such as the sudden onset of her condition, followed by more frequent headaches, and a stiff neck, which can be a sign of systemic illness.

Other signs that may mean a headache is serious include:

  • Thunderclap headache (reaching maximum severity immediately).
  • Positional headache (pain in a particular location).
  • Headaches initiated by exertion.
  • New headaches (especially over age 50).
  • Change in headache pattern.
  • Worrisome neurologic symptoms, such as numbness and loss of function.
  • Headache that never goes away.
  • Systemic symptoms (fevers, chills, weight loss, night sweats).

Our patient was admitted to the critical-care unit and placed on a breathing machine so a neurosurgeon could drain the pressure in her head.  She was started on medications to prevent complications (such as epilepsy) and eventually made a steady recovery.

Erik J. Blutinger, M.D., M.Sc., is a resident in emergency medicine at the Hospital of the University of Pennsylvania.