What could be the cause of headache and vomiting symptoms?

Headache and Vomiting: Differential Diagnosis and Urgent Evaluation

The combination of headache and vomiting is a medical emergency until proven otherwise, requiring immediate evaluation to exclude life-threatening causes including subarachnoid hemorrhage, meningitis, intracerebral hemorrhage, and increased intracranial pressure. 1, 2, 3

Immediate Risk Stratification

Life-Threatening Causes Requiring Emergency Evaluation

Subarachnoid Hemorrhage (SAH)

• "Worst headache of my life" is reported by 80% of patients with aneurysmal SAH 4
• Headache onset may be associated with nausea/vomiting (77% of cases), brief loss of consciousness (53%), and nuchal rigidity (35%) 1
• Sentinel or "warning leak" headaches occur in 19-43% of patients within 2-8 weeks before major rupture 1, 4
• Non-contrast head CT has 98-100% sensitivity in the first 12 hours and remains the cornerstone of diagnosis 1, 4
• If CT is negative but clinical suspicion remains high, lumbar puncture must be performed to evaluate for xanthochromia 1, 4
• Misdiagnosis occurs in 12% of cases and is associated with nearly 4-fold higher likelihood of death or disability 1, 4

Meningitis

• All patients with suspected meningitis require immediate emergency department evaluation via ambulance and consideration of lumbar puncture 2
• The classic triad of neck stiffness, fever, and altered consciousness is present in less than 50% of bacterial meningitis cases 2
• Young adults (20-30 years) are particularly susceptible to viral meningitis and meningococcal infection 2
• Do NOT rely on Kernig's or Brudzinski's signs—they have high specificity but low sensitivity 2

Intracerebral Hemorrhage (ICH)

• Vomiting occurs more frequently with ICH than with ischemic stroke or SAH, making it a distinguishing clinical feature 3
• Symptoms typically develop as part of smooth progression over minutes to hours while patient is active 3
• Persistent fever >37.5°C for >24 hours combined with vomiting correlates with ventricular extension and predicts poor outcomes in 83% of patients 3

Increased Intracranial Pressure/Mass Lesions

• Headache with vomiting, particularly if worse in morning or with position changes, suggests elevated ICP 5, 6
• Papilledema, focal neurological deficits, or altered mental status mandate immediate neuroimaging 2, 5

Red Flags Requiring Immediate Neuroimaging

Any of the following warrant urgent CT or MRI:

• Abnormal neurological examination 7
• Altered mental status or decreased level of consciousness 2, 6
• Focal neurological deficits or cranial nerve palsies 4, 7
• "Thunderclap" or sudden severe headache 1, 6
• First or worst headache of patient's life 1, 4
• Progressive headache over days to weeks 4, 7
• Headache that wakes patient from sleep 7
• Age >50 years with new-onset headache 5
• Immunocompromised status 5, 7
• Recent head trauma 1
• Seizures 1

Primary Headache Disorders (After Excluding Secondary Causes)

Migraine

• Headache is the most frequently reported symptom in migraine 1
• Nausea should be treated with an antiemetic drug, and a nonoral route of administration should be selected when nausea or vomiting present early as significant components of migraine attacks 1
• First-line treatment: NSAIDs (aspirin, ibuprofen, naproxen sodium) or acetaminophen-aspirin-caffeine combination 1
• Acetaminophen alone is ineffective for migraine 1
• Migraine-specific agents (triptans, DHE) should be used when attacks do not respond to NSAIDs 1
• Triptans contraindicated in uncontrolled hypertension, basilar or hemiplegic migraine, or patients at risk for heart disease 1

Status Migrainosus

• Severe, continuous migraine lasting up to one week 1
• May require parenteral therapy with ketorolac, metoclopramide, or prochlorperazine 1, 8
• Steroid therapy may be treatment of choice 1

Diagnostic Approach Algorithm

Step 1: Immediate Assessment

• Document vital signs, mental status, and complete neurological examination 2, 6
• Assess for red flags listed above 5, 6, 7

Step 2: Determine Acuity

• Thunderclap/sudden onset → Emergency neuroimaging immediately 1, 6
• Progressive over days/weeks with red flags → Urgent neuroimaging 6, 7
• Recurrent episodic pattern without red flags → Consider primary headache 6

Step 3: Neuroimaging Decision

• CT brain without contrast is first-line for acute presentations 1, 2
• Perform CT before lumbar puncture if focal findings, decreased consciousness, or papilledema present 2
• MRI with appropriate sequences if CT negative but high clinical suspicion 1

Step 4: Lumbar Puncture Indications

• Suspected meningitis (after CT if indicated) 2
• CT-negative suspected SAH with high clinical suspicion 1, 4
• Suspected spontaneous intracranial hypotension 1

Critical Pitfalls to Avoid

• Failure to obtain neuroimaging is the most common diagnostic error in SAH 1, 4
• Do not dismiss vomiting as simple gastroenteritis when accompanied by headache, altered consciousness, or focal deficits—these combinations demand immediate CT imaging 3
• Do not use opioids for primary headache disorders—they have scarce effectiveness and risk dependency and rebound headaches 1, 8
• Limit acute migraine treatment to no more than twice weekly to avoid medication overuse and rebound headaches 1
• Dismissing "warning headaches" can increase odds of early rebleeding 10-fold in aneurysmal SAH 4
• Do not rely solely on classic presentations—atypical presentations are common in serious conditions 1, 2, 6

Treatment Considerations After Excluding Emergencies

For Acute Migraine with Vomiting:

• Use nonoral route: intranasal DHE, subcutaneous sumatriptan, or parenteral ketorolac 1
• Antiemetics: metoclopramide or prochlorperazine 1, 8
• IV hydration only if dehydration is ascertained 8

Pediatric Considerations:

• Only ibuprofen and sumatriptan are significantly more effective than placebo in children 7
• Age <6 years is a red flag requiring further investigation 7