Headache and/or seizures may accompany onset. The association is temporal, often very close, and this is the main evidence for a causal link, though there are also very plausible mechanisms for causation.
However, several potential mechanisms may apply in individual patients, and it may be impossible to disentangle the many possibilities, particularly in infarction. Seizures may occur, particularly with the more rapid and higher levels achieved when cocaine is injected or smoked as “crack”. In patients with pre-existing enhanced risk of seizures (for example, those with epilepsy or taking other epileptogenic drugs), intranasal cocaine may apparently precipitate fits. When they do occur, seizures may be prolonged and fatal, not only through the secondary consequences of prolonged seizures but also perhaps through the direct effect of the high drug levels. Hyperpyrexia may develop because of direct effects on the hypothalamus and also the agitation and hyperactivity that these stimulant drugs tend to produce.
These may contribute along with muscle vasoconstriction, central rigidity, and seizures to the rhabdomyolysis that sometimes occurs in more sick patients. In addition, cocaine may have a direct toxic effect on skeletal muscle (as it does on cardiac muscle).
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