Differential Diagnosis for Headache and Syncopal Episode

The patient's presentation of a terrible headache and a syncopal episode as the reason for his fall requires a thorough differential diagnosis to ensure all potential causes are considered. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Hypertensive Emergency: This condition is characterized by severely elevated blood pressure, which can lead to a headache and potentially cause a syncopal episode due to the body's inability to maintain adequate cerebral perfusion. The sudden onset of a severe headache, often described as "the worst headache of my life," is a classic presentation of a hypertensive emergency.

• Other Likely Diagnoses

  • Migraine with Aura: Although migraines are common, when they are accompanied by an aura and lead to a syncopal episode, they become a significant concern. The headache can be severe, and the aura symptoms might include neurological deficits that could predispose to falling.
  • Dehydration: Severe dehydration can lead to both headaches and syncopal episodes due to decreased blood volume and subsequent reduced cerebral perfusion.
  • Orthostatic Hypotension: A drop in blood pressure upon standing can cause dizziness and fainting, which might be preceded by a headache due to decreased blood flow to the brain.

• Do Not Miss Diagnoses

  • Subarachnoid Hemorrhage (SAH): Although less common, SAH is a medical emergency that presents with a sudden, severe headache (often described as "thunderclap") and can be associated with loss of consciousness or syncopal episodes. Missing this diagnosis can be fatal.
  • Intracranial Hemorrhage: Similar to SAH, other types of intracranial hemorrhages (e.g., intraparenchymal, subdural, epidural) can present with headache and altered mental status, including syncope, and require immediate medical attention.
  • Cardiac Causes (e.g., Arrhythmias, Myocardial Infarction): Certain cardiac conditions can lead to reduced cerebral perfusion, resulting in syncope and potentially headache. These conditions are critical to identify due to their high mortality rate if left untreated.

• Rare Diagnoses

  • Pheochromocytoma: A rare tumor of the adrenal gland that can cause episodic hypertension, leading to headaches and potentially syncopal episodes due to the sudden surge in blood pressure.
  • Temporal Arteritis: An inflammatory condition affecting the blood vessels, particularly in older adults, which can cause headaches and visual disturbances. While less likely to cause syncope directly, the severe headache and potential for vision loss make it a diagnosis not to overlook.
  • Cerebral Venous Thrombosis: A rare cause of stroke that can present with headache and potentially lead to seizures or loss of consciousness, including syncopal episodes, due to increased intracranial pressure.