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Is It Just a Bad Headache — or Something Worse?

10 signs that should send you to the ER

En español | Usually, a headache is … well, just a headache.

"Ninety-five percent of the time, even an agonizing headache is not serious and doesn't mean you have a brain tumor," says Brian M. Grosberg, M.D., associate professor of neurology at the Albert Einstein College of Medicine and codirector of its famed Montefiore Headache Center, in the Bronx, N.Y. "An over-the-counter pain reliever, a cup of coffee or a nap usually brings relief."

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Symptoms, bad headache and nausea. Illness, vomiting.

Pounding headache? Don't dismiss it — it could be a sign of a more serious problem. — Photo by Christopher Robbins/Getty Images

Still, severe headaches can be frightening because — sometimes — they are a sign of a serious condition, one you don't want to minimize or misdiagnose. How can you tell whether it's a true headache emergency? Here are 10 red flags to watch out for. If you ever spot one, call 911 or get yourself (or your loved one) to an emergency room — stat.

1. It's the worst headache you've ever had. One of the first things Grosberg teaches his medical students is that when people use this sort of language about a headache, they must be seen immediately. Called a "thunderclap headache," this sudden, excruciating pain, which reaches maximum intensity within seconds to a minute, may signal the rupture of a brain aneurysm, when a blood vessel in the brain tears, cutting off the blood supply to a part of it. Brain aneurysms can be treated, but only if you get to the ER within hours of an attack.

2. You have neurological symptoms. A headache coupled with confusion, dizziness, memory loss, slurred speech, loss of balance, weakness on one side of the body, seizures or blurred or double vision could signal a stroke or brain tumor, so always demand prompt medical action.

3. You're 50-plus and this is your first-ever acute headache.
Throbbing migraines since college may be incapacitating, but they're not as worrisome as a first-time headache in an older adult, which, if severe, could signal a stroke or brain tumor.

However, keep in mind that the symptoms of a brain tumor vary greatly, depending on a tumor's size, location and type. Although many people believe that a severe early-morning headache coupled with nausea or vomiting is a sure sign of a tumor, studies have found that's true in less than 50 percent of cases. Indeed, most patients with these types of symptoms have a tension headache instead.

4. You've had bad headaches before, but this one is different. Any major change in the type or pattern of your headaches should be checked out right away. This could signal a number of conditions ranging from life-threatening (stroke, tumor or meningitis) to less serious "rebound" headaches caused by too much pain medication.

5. You have a fever, stiff neck or vomiting. These symptoms along with a headache could point to meningitis — a swelling of the membranes lining the spinal cord and brain. Although both the bacterial and viral forms of this illness are relatively rare in older people, both can be fatal. Older patients with meningitis may not have the telltale stiff neck common in younger people. Their symptoms often include the confusion and loss of consciousness that closely resemble a stroke.

6. Your headache started after you hit your head. Even if it was a moderate bump and you didn't black out, you should get to the ER because your head pain may stem from a concussion. Although most such injuries are not serious, concussions with bruising or bleeding on the brain can lead to vision loss, balancing problems, confusion and even death.

7. Your head pain comes on repeatedly, in severe, sudden flashes, when you cough, sneeze, bend down, or strain during a bowel movement or sex. This may be a sign of a worrisome condition such as vascular disease of the head or neck, an aneurysm or tumor, or other structural problems in the brain.

8. You have cancer or HIV/AIDS and develop a new headache. Any new headache in a patient with HIV/AIDS could mean a brain infection such as meningitis, which should be evaluated promptly by a doctor. A new headache in a cancer patient doesn't necessarily demand a trip to the ER but should be seen promptly by the patient's own doctor. Shingles (herpes zoster) around the eye or forehead can cause permanent damage to eye and vision loss.

9. You have a severe headache plus pain and tenderness on your scalp, temples and jaw. This could a sign of temporal arteritis, an inflammation of the arteries that occurs almost exclusively in older adults. Believed to be an autoimmune condition, temporal arteritis must be treated as soon as possible with steroids to avoid permanent loss of vision.

10. You have a sudden, severe headache and redness in one eye. A headache and a painful, red eye can be caused by a number of conditions that are not life-threatening, including corneal injury and eye inflammation. However, one form of acute glaucoma, involving rapid buildup of pressure on the optic nerve, can occur suddenly with these same symptoms. Left untreated, it can lead to irreversible vision loss. So just in case, you must get to an ER.

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Common Headaches — When to Call the Doctor

The most common types of headache — tension and migraine — tend to lessen as we age, thanks to hormonal shifts as well as life changes that often dial down stress.

But other kinds of headaches do happen more frequently in older people — and a few only occur in those over 50. For example, thyroid disorders and sleep apnea, which become more common as we age, can prompt severe headaches. So can various medications necessary to treat pain, high blood pressure or asthma.

If you experience any of the following, a visit to your doctor, who knows your history, can bring reassurance and relief.

  • Hypnic or "alarm clock" headaches. If you're awakened by dull pain in the front of your head every night around the same time — usually 3 or 4 a.m. — it may be a hypnic headache. Doctors aren't sure what causes these headaches, which can last from 15 minutes to a few hours, though they believe they're related to the body's circadian rhythm. Your doctor may need to do tests to make sure that the headaches are not being caused by another disorder, and can prescribe a number of preventive medications. Some people also find that caffeine taken right before bed can help.
  • Migraine-like auras. Those with a history of migraines may find that while head pain diminishes, the auras — including problems such as seeing shimmering lights, graying out of vision, difficulty seeing on one side of your visual field or spotsthat used to warn of an impending attack — continue. Several nondrug treatments, such as meditation and biofeedback, as well as new ways to deliver older medications, look promising. Those with these symptoms can discuss treatment options with their doctor, says Brian M. Grosberg, M.D., associate professor of neurology at the Albert Einstein College of Medicine.
  • Rebound or overuse headaches. If you're taking several medications a day — say, pain pills for arthritis and an over-the-counter drug for a cold — you may unwittingly be worsening your headaches. So call your doctor. He or she can help wean you off the culprit drugs and put you on a healthier treatment plan.
  • Trigeminal neuralgia (also known as tic douloureux). Sharp, searing pain on one side of your face may be triggered when a blood vessel on the side of your face presses against the nerve near the brain stem. Simple daily movements such as chewing, laughing, brushing your teeth or merely touching your face can set off pain, which can come and go or last for months at a time. Medication or surgery may be necessary to relieve the pain.

Margery D. Rosen is a freelance writer specializing in health, psychology and relationships.

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