Approach to the International Traveler With Neurological Symptoms

Kiran T Thakur; Joseph R Zunt


Future Neurology. 2015;10(2):101-113. 

In This Article

Headache Without Meningismus

Common causes of headaches in travelers include dehydration, sleep deprivation, excessive alcohol intake and medication noncompliance. Patients with history of chronic headache often have exacerbations related to travel, which is typically multifactorial. A thorough history should include: headache triggers, medication use, social activities and living conditions during travel. Another important condition to consider is airplane headaches, a recently described headache disorder occurring exclusively in the setting of airplane flights. In a report of 75 subjects who had headache attacks during airplane travel, the condition was most commonly described as a severe unilateral fronto-orbital headache, which peaked after several seconds and lasted approximately 30 min. The majority of headaches occurred during the ascent or landing portion of the flight. Analgesics and nonsteroidal anti-inflammatory medications (NSAIDs), when taken prophylactically, may prevent recurrent attacks.[38]

Headache is the cardinal feature of high-altitude sickness, with the potential deadly complication of high-altitude cerebral edema. In the patient returning from a recent climbing expedition, high-altitude sickness should be included in the differential diagnosis for the patient presenting with headache, anorexia, nausea, dizziness and malaise.[39] High-altitude cerebral edema is characterized by truncal ataxia, decreased level of consciousness, and mild fever with or without headache.[40] Without appropriate treatment, coma and death due to cerebral herniation may rapidly occur. For both high-altitude sickness and high-altitude cerebral edema, patients most typically develop symptoms within the first few days after arrival to high-altitudes, and are therefore likely to present to a local hospital near to where they trekked.[27] Acute mountain sickness and high-altitude cerebral edema typically occur above 2500 meters, with the majority of cases occurring above 4500 meters.[41–44] Treatment of the patient presenting with acute mountain sickness should include at least a day of rest and NSAIDS. If symptoms are severe, immediate descent, dexamethasone and supplemental oxygen are indicated. Pre-ascent recommendations should advise ascending no more than 300–500 m per day at altitudes above 3000 m and include a rest day every 3–4 days. Prophylactic use of acetazolamide or dexamethasone is also recommended.