Persistent Evening Headaches in a 48-Year-Old Male with Subdural Hematoma and Cerebral Edema

Case at a Glance

A 48-year-old male presents with persistent evening headaches occurring daily at 6-7 PM for two months, initially attributed to diabetes and hypertension but later found to be associated with a 5mm subdural hematoma and cerebral edema on CT imaging.

Patient's Story

The patient, a 48-year-old male with a 5-year history of daily alcohol consumption (100-150ml), began experiencing daily headaches occurring consistently between 6-7 PM approximately two months prior to presentation. Initially, these episodes were thought to be related to lifestyle factors and sleep deprivation. The patient had recently ceased alcohol consumption one week prior to the current evaluation.

Initial Assessment

Initial workup revealed significantly elevated HbA1c of 12% and hypertension. The attending physician initially attributed the headaches to poor glycemic control and elevated blood pressure. The patient was started on antihypertensive and antidiabetic medications, which successfully controlled both blood pressure and blood glucose levels within the therapeutic range.

The Diagnostic Journey

Despite normalization of blood pressure and glucose levels, the patient's headaches persisted without improvement. This prompted neurological evaluation and brain imaging. CT scan of the head revealed a 5mm subdural hematoma with associated cerebral edema. Initially, the headache episodes were brief (15-30 minutes duration), but recently progressed to continuous, prolonged episodes lasting several hours.

Final Diagnosis

Subdural hematoma (5mm) with cerebral edema, likely related to chronic alcohol use. Secondary diagnoses include poorly controlled diabetes mellitus (HbA1c 12%) and hypertension.

Treatment Plan

Conservative management was initially recommended by the consulting neurologist, who determined that surgical intervention was not indicated at the current stage. The patient was prescribed medical therapy for the subdural hematoma and cerebral edema. Complete alcohol cessation was maintained. Continued management of diabetes and hypertension with appropriate medications.

Outcome and Follow-up

Despite three days of prescribed medical therapy, the patient's headaches have not improved and have progressed from intermittent brief episodes to continuous, prolonged pain. Due to the lack of clinical improvement and concern for potential deterioration, the family is seeking a second neurological opinion at a tertiary care facility for further evaluation and management recommendations.