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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Headaches at High Altitude

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On a recent trip to Mount Everest Basecamp, we encountered a number of medical situations. One stands out as being somewhat unique  - so much that at some point we will write it up as a “case report” and submit it for consideration for publication in the medical literature.

A young man who was in excellent condition and without any immediately prior illness during the trip suffered a migraine headache at approximately 11,000 feet altitude. At any altitude above where we began our trek (around 9000 feet), an altitude-related headache would be of concern. This would first conclude acute mountain sickness (AMS) and if progressively more severe, high altitude cerebral edema (HACE). He recognized his headache for what he considered to be a typical migraine pattern for him, and self-treated with his usual medications. With rest, hydration and his medications, he felt much better and his headache fully resolved. We were careful to be certain that there was no residual headache, and in particular, any symptoms that would have been more likely to represent AMS than a migraine.

He felt well for the next few days, but then once again had the onset of a headache after attaining an altitude of approximately 15,000 feet. The headache once again seemed liked a migraine, but had a slightly different character, including more of a global (diffuse pain) nature and nausea. The new headache resolved with rest, but yet another headache similar in nature occurred as he ascended above 16,000 feet.  Despite an attempt to rest, hydrate, change the maintenance (preventative for AMS) dose of acetazolamide to a “rescue” or treatment dose of 250 mg twice a day, the headache progressed and the patient became disabled by his headache, repeated nausea and vomiting, and weakness. This was obviously severe AMS. Despite treatment with an oral steroid (dexamethasone) and inhaled oxygen, he could not turn the corner on his AMS sufficiently to tolerate a hike down to a lower altitude (where the amount of oxygen in the air would have been higher). Evacuation by helicopter to a lower altitude became necessary.

In retrospect, we should have appreciated sooner the different nature of the second and third headaches. In that event, we might have made more prompt and effective interventions.  We’re all grateful that his recovery was swift. I have certainly learned once again the various presentations of AMS and will be more vigilant in the future.

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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