Subdural Hemorrhage Can Present with Tension-Type Headache Characteristics
Subdural hemorrhage (SDH) can present with tension-type headache characteristics, though this is not the typical presentation and warrants careful clinical evaluation to avoid misdiagnosis. 1
Clinical Presentation of SDH vs. Tension-Type Headache
Typical SDH Presentation
- Classic presentation: Sudden severe headache ("worst headache of life") with thunderclap onset 1
- Often associated with:
- Nausea/vomiting (77% of cases)
- Loss of consciousness (53%)
- Nuchal rigidity (35%)
- Focal neurological deficits
- Seizures (up to 20% of cases, especially in first 24 hours)
Atypical SDH Presentations
- Headache may be the only presenting symptom in some cases 2, 3
- Headache characteristics can be variable and may mimic other headache types
- In chronic/subacute SDH, headache may be less severe and more insidious in onset 4
- Only 22.6% of chronic SDH patients report headache as a symptom 5
Tension-Type Headache Characteristics
- Bilateral, mild to moderate pain
- Pressing or tightening quality
- Not aggravated by routine physical activity
- Lacks accompanying symptoms typical of migraine 1
Key Differentiating Factors
Red Flags Suggesting SDH Rather Than Tension-Type Headache
- Recent trauma (even mild)
- Recent lumbar puncture or spinal anesthesia
- Change in headache pattern or character
- Headache worsening over time
- New focal neurological symptoms
- Altered mental status
- Headache associated with positional changes (may indicate intracranial hypotension)
- Subdural hematoma as a complication of spontaneous intracranial hypotension 1
Risk Factors for SDH
- History of trauma (even minor)
- Anticoagulation therapy
- Coagulopathy
- Advanced age
- Alcohol misuse
- Recent lumbar puncture (can lead to intracranial hypotension and subsequent SDH) 1
Diagnostic Approach
When to Suspect SDH in a Patient with Apparent Tension-Type Headache
- Headache following trauma (even minor)
- Headache that is persistent or worsening
- Headache with positional component
- Headache unresponsive to typical treatments
- Headache with any neurological symptoms
Imaging Recommendations
- Non-contrast head CT remains the cornerstone of diagnosis for acute SDH 1
- Sensitivity close to 100% in first 3 days
- Sensitivity decreases after 5-7 days
- MRI with fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging, and gradient echo sequences is superior for subacute or chronic SDH 1, 6
- Neuroimaging should be performed with a low threshold in cases of:
- Persistent headache after trauma
- Change in headache pattern
- Neurological symptoms
- Headache with red flags
Clinical Implications
Pitfalls to Avoid
- Misdiagnosis is common (historically up to 64%, more recently around 12%) 1
- Most common diagnostic error is failure to obtain a non-contrast head CT
- Assuming a tension-type headache diagnosis without considering secondary causes
- Overlooking minor trauma history
- Failing to recognize sentinel headaches that may precede major rupture
Management Considerations
- SDH with mass effect may require urgent neurosurgical intervention 1
- Small or asymptomatic hematomas may be managed conservatively
- Patients with spontaneous intracranial hypotension and SDH require treatment of the underlying CSF leak 1
In conclusion, while SDH typically presents with sudden severe headache, it can occasionally manifest with features similar to tension-type headache, particularly in subacute or chronic cases. Clinicians should maintain a high index of suspicion, especially in patients with risk factors or an atypical clinical course, and have a low threshold for neuroimaging to avoid potentially life-threatening misdiagnosis.