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

In people with spinal cord injury, the body’s warning signals get disrupted. Even though the bladder may be full or clothing might be tight, the person might not notice it — yet blood pressure can spike dramatically. The warning signs are sudden severe headache and sweating. In such cases, the first step is to help the person sit upright, loosen any tight clothing, check whether the bladder is full, and call 120 right away.

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

This episode is known as autonomic dysreflexia. A systematic review examined four major databases — Medline, CINAHL, EMBASE, and PsycINFO — and included 31 studies, 6 of which were randomized controlled trials. The review clearly states that non-drug management during an episode consists of three steps: positioning the patient upright, loosening tight clothing, and removing any triggering factors. These steps are supported by clinical consensus and physiological evidence, and are classified as Level 5 evidence. Antihypertensive drugs are only used when blood pressure remains elevated; phentolamine has Level 1 evidence, while nifedipine and prostaglandin E2 have Level 2 evidence. Preventive strategies mainly target common triggers such as urinary retention and surgical procedures; most of these preventive measures are backed by Level 4 or Level 5 evidence.

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.

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