Throbbing severe headache, with sudden onset, in patients with spinal cord injury and autonomic dysreflexia. The latter, which can be life-threatening, manifests as a paroxysmal rise in blood pressure among other symptoms and clinical signs, and is often triggered by bladder or bowel irritation (by infection, distension or impaction).

Diagnostic criteria:
  1. Headache of sudden onset, fulfilling criterion C
  2. Presence of spinal cord injury and autonomic dysreflexia documented by a paroxysmal rise above baseline in systolic pressure of ≥30 mm Hg and/or diastolic pressure of ≥20 mm Hg
  3. Evidence of causation demonstrated by at least two of the following:
    1. headache has developed in temporal relation to the rise in blood pressure
    2. either or both of the following:
      • a) headache has significantly worsened in parallel with increase in blood pressure
      • b) headache has significantly improved in parallel with decrease in blood pressure
    3. headache has at least two of the following four characteristics:
      • a) severe intensity
      • b) pounding or throbbing (pulsating) quality
      • c) accompanied by diaphoresis cranial to the level of the spinal cord injury
      • d) triggered by bladder or bowel reflexes
  4. Not better accounted for by another ICHD-3 diagnosis.

The time to onset of autonomic dysreflexia after spinal cord injury is variable and has been reported from 4 days to 15 years.

Given that autonomic dysreflexia can be a life-threatening condition, its prompt recognition and adequate management are critical. Typically, 10.3.5 Headache attributed to autonomic dysreflexia is a sudden-onset, severe headache accompanied by several other symptoms and clinical signs including increased blood pressure, altered heart rate and diaphoresis cranial to the level of spinal cord injury. These are triggered by noxious or non-noxious stimuli, usually of visceral origin (bladder distension, urinary tract infection, bowel distension or impaction, urological procedures, gastric ulcer and others) but sometimes somatic (pressure ulcers, ingrown toenail, burns, trauma or surgical or invasive diagnostic procedures).