School picture day is often dreaded by children and their parents. Although finding the perfect outfit and keeping it clean, making sure remnants of breakfast aren’t present in the child’s teeth, and getting their hairstyle just right are typical stressors surrounding picture day, most parents do not think about their young student having a potential medical emergency just hours before saying “cheese.”

A 6-year-old girl presented to the emergency department a few hours after a brief syncopal episode. As the patient’s mother was curling her daughter’s hair in preparation for picture day, she noticed that her daughter was becoming restless and that her body began to sway. When describing the incident, the mother said, “I just thought she was becoming restless because she didn’t want her hair curled.”

The mom noticed something was wrong when her little girl’s head fell backward and her body went limp. The mother was able to cradle her daughter’s body to protect it from hitting any of the porcelain fixtures in the bathroom, but once the patient’s body was laid on the bathroom floor, the mom noticed a brief twitching of her upper extremities that lasted for a few seconds. After being unresponsive for approximately 30 seconds, the patient returned to her baseline mental status and went to school.

Understanding Syncope

Syncope is defined as a sudden, brief loss of consciousness associated with a loss of postural tone from which recovery is spontaneous. Syncopal episodes account for about three to five percent of emergency department visits and one to six percent of hospital admissions. The most common causes of syncope are “unknown” (34–36 percent), vasovagal (18–21 percent), and cardiac (9.5–18 percent).¹

All patients who present to the emergency department after a syncopal episode should have a thorough history taken, a physical exam, and an ECG.¹ Based on the patient’s age, comorbidities, history, and symptoms, a more thorough workup can be carried out. When interpreting the patient’s ECG, be mindful and document the presence or lack of conduction and interval abnormalities, ischemia, arrhythmias, delta waves to suggest Wolff-Parkinson-White, Brugada sign, and evidence of hypertrophic obstructive cardiomyopathy (HOCM).¹ If the patient’s history, physical exam, ECG, and other testing indicate the patient is low risk, most patients in this subgroup will be labeled as having experienced neurocardiogenic syncope or vasovagal syncope. In these cases, obtaining a pertinent history with directed questions regarding the events immediately preceding the syncopal episode is critical.

Hair-Grooming Syncope

When evaluating these patients with low-risk syncope, how often have you asked: “Were you getting your hair groomed when you passed out?”

Hair-grooming syncope is a rare subtype of neurocardiogenic syncope that is precipitated by different acts of hair care or grooming. Evans, et al., conducted a retrospective study in which they reviewed a database of pediatric patients being evaluated for syncope in the outpatient pediatric cardiology clinic. Hair grooming triggered episodes in seven percent of the cohort—78% of whom were girls. Hair combing was the most common trigger in girls, whereas hair cutting predominated in boys.

Cardiac testing workup demonstrated normal ECGs in 109 of 111 with two patients having minor noncontributory arrhythmias; and 105 of 111 had normal ECG with six patients having minor noncontributory structural abnormalities.² The authors speculate that the mechanism of hair grooming syncope is related to pain from hair pulling or scalp stimulation of the trigeminal nerve, which precipitates a neurocardiogenic reflex. Although the authors do not specify which branch(es) of the trigeminal nerve are affected, all branches of the trigeminal nerve innervate sensitive areas of the scalp as shown in Image 1.

Image 1. All branches of the trigeminal nerve innervate sensitive areas of the scalp. (Click to enlarge.)

Emergency physicians must decide who can be safely discharged with outpatient follow-up (low-risk) and who requires admission for monitoring (high-risk. The next time you see a patient in the emergency department who experienced a syncopal episode when getting their hair combed or cut, you can now potentially “brush” it off as hair grooming syncope.

Teaching Points:

• An ECG should be obtained on all patients who present to the emergency department after a syncopal episode.
• Syncope during hair grooming practices is thought to be a type of neurocardiogenic syncope that occurs because of stimulation of the scalp nerve fibers and/or branches of the trigeminal nerve.
• Although the differential diagnosis for syncope is broad, most causes of syncope are benign, so obtaining a thorough history and performing a physical exam to help identify high-risk syncope are paramount in determining additional workup and disposition.

Dr. Halupa is an emergency physician at the Geisinger St. Luke’s Hospital in Orwigsburg, Pa. 

References

1. De Lorenzo RA. (2018). Syncope. In Walls R, Hockberger R., Gausche-Hill M, et al. (Eds.), Rosen’s Emergency Medicine: Concepts and Clinical Practice (pp. 115-122). Elsevier.
2. Evans WE, Acherman R, Kip K, Restrepo H. Hair-grooming syncope in children. Clinical Pediatrics. 2009; 48(8): 834-836.