Vomiting in Head Bleeds: Clinical Characteristics
Vomiting in intracerebral hemorrhage (ICH) is more common than in ischemic stroke or subarachnoid hemorrhage, occurring in approximately 77% of cases, and typically presents as a non-specific symptom of increased intracranial pressure alongside headache and altered consciousness. 1
Key Clinical Features
Frequency and Presentation
- Vomiting occurs more frequently with ICH than with either ischemic stroke or subarachnoid hemorrhage, making it a distinguishing clinical feature 1
- In subarachnoid hemorrhage specifically, vomiting is present in 77% of confirmed cases and accompanies the characteristic "worst headache of my life" 2, 3
- The vomiting results from sudden surge in intracranial pressure as the hematoma volume increases pressure within the closed cranial vault 4
Associated Symptoms
- Vomiting typically occurs alongside headache, nausea, and alterations in consciousness - these represent the classic triad of increased intracranial pressure 4
- Nuchal rigidity (neck stiffness) may accompany vomiting, particularly in subarachnoid hemorrhage (35% of cases) 2
- Photophobia and focal neurological deficits often coexist with the vomiting 2
Temporal Pattern and Progression
Onset Characteristics
- The vomiting develops as part of a smooth symptomatic progression over minutes to hours, which is uncommon in ischemic stroke and rare in subarachnoid hemorrhage 1
- Symptoms typically begin while the patient is active, with focal neurological deficits progressing alongside the vomiting 1
Clinical Significance
- Persistent fever >37.5°C for >24 hours combined with vomiting correlates with ventricular extension of hemorrhage and predicts poor outcomes in 83% of patients 1
- The presence of vomiting warrants urgent neuroimaging, though vomiting alone has a positive predictive value of only 4% for significant head injury requiring intervention 5
Critical Pitfalls to Avoid
- Do not dismiss vomiting as simple gastroenteritis when accompanied by headache, altered consciousness, or focal neurological deficits - these combinations demand immediate CT imaging 1
- Recognize that vomiting with headache can indicate other serious conditions including cerebral venous thrombosis, which requires immediate anticoagulation 6
- The combination of vomiting with progressive neurological deterioration indicates high risk for cardiopulmonary instability and requires neurocritical care monitoring 1