Sinister Headache Causes: Meningitis, Intracranial Tumours, Brain tumours, Subacute Carbon Monoxide Poisoning

The main question is how can we recognise a sinister headache. The major red flag is age. Three-quarters of migraine sufferers have had their first migraine by the age of 30 and it is increasingly less likely that the first attack be much above 30. Abrupt onset with vomiting is another warning. The patient should seek expert medical opinion.

Causes of sinister headache that must not be missed include

1. Meningitis: usually accompanied by fever and neck stiffness in an obviously ill patient.
2. Intracranial tumours (brain tumours): produce headache when they are large enough to cause raised intracranial pressure, which is usually apparent from the history. Papilloedema or focal neurological signs, or both, will usually be present. Fortunately these are very rare.
3. Subarachnoid haemorrhage: headache is often described as the worst ever, and is usually (but not always) of sudden or ictal onset. Neck stiffness may take hours to develop. In elderly patients particularly, classic symptoms and signs may be absent.
4. Temporal arteritis: headache is persistent but often worse at night and sometimes severe, in a patient over 50 who does not feel entirely well. It may be accompanied by marked scalp tenderness.
5. Primary angle closure glaucoma: rare before middle age, may present dramatically with acute ocular hypertension, a painful red eye with the pupil midodilated and fixed and, essentially, impaired vision, and nausea and vomiting. In other cases, headache or eye pain is episodic and mild. The diagnosis is suggested if patient reports coloured halos around lights.
6. Idiopathic intracranial hypertension: rare cause of headache; occurs especially with obese young women. May not be evident on history alone; papilloedema indicates the diagnosis.
7. Subacute carbon monoxide poisoning: uncommon but potentially fatal. Symptoms include headaches, nausea, vomiting, giddiness, muscular weakness, dimness of vision, and double vision.

Source: Dr Andrew Dowson

Publication Date: July 2003

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