Sudden severe headache and sweating after spinal cord injury: first help the person sit upright, loosen tight clothing, and call 120

No cost at all. Just three simple actions, completed in just a few dozen seconds.

This episode is called autonomic dysreflexia. A systematic review searched Medline, CINAHL, EMBASE, and PsycINFO, included 31 studies, and of those 6 were randomized controlled trials. The review states that non-drug management during an episode is three steps: put the patient in an upright position, loosen tight clothing, and remove the triggering stimulus. Those three steps rest on clinical consensus and physiology data and are Level 5 evidence. The review body text states that episodes are most common with injury at thoracic level 6 or above, and the most common triggers are bladder or bowel irritation. Stimuli below the injury level set off a large sympathetic discharge, blood pressure rises sharply, and sensation below the injury is partly or wholly gone. Symptoms include severe headache and heavy sweating above the injury level; there may also be no symptoms at all. Untreated, it can lead to intracranial hemorrhage, seizures, or death. No study specifically measured the effect of sitting up during an episode, but when people with spinal cord injury go from lying flat to sitting or tilting, resting blood pressure falls clearly. Antihypertensive drugs are used only when blood pressure stays high; among them prazosin has Level 1 evidence, and nifedipine and prostaglandin E2 have Level 2 evidence. The review also states that prevention mainly targets urogenital and surgical triggers, and most of that evidence is only Level 4 or Level 5

Krassioukov A, Warburton DE, Teasell R, Eng JJ; Spinal Cord Injury Rehabilitation Evidence Research Team (2009). A systematic review of the management of autonomic dysreflexia after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 90(4):682-695. https://doi.org/10.1016/j.apmr.2008.10.017

This B rating reflects the fact that there are no randomized controlled trials supporting those three immediate actions — only clinical consensus and physiological reasoning. The review itself notes that most of these measures are supported solely by non-controlled studies. Medication administration is strictly a medical professional’s responsibility; family members must not give antihypertensive drugs at home. Lying the person down can further raise blood pressure, so sitting upright is essential. Family members and caregivers must also master these three steps. This condition must never be mistaken for ordinary headaches.