What is Currently the Best Investigational Approach to the Patient With Sudden‐Onset Severe Headache?

Presentation of Case – Ane Skaare Sjulstad, MD, Adult Neurology Resident, Nordland Hospital, Bodø, Norway A 48-year-old man with no previous medical history suddenly experienced severe intense retro-bulbar pain of pulsating character on the right side, and was seen in the emergency department 7 hours later. He was then alert and oriented, but in excruciating pain. There was no neck stiffness and no fever. The blood pressure was 141/80 mm Hg, and the pulse regular with a frequency of 48. Neurological examination was normal. Query by Dr. Sjulstad: When does actually sudden-onset severe headache represent a potential life-threatening condition? Response by Dr. Alstadhaug: There is no definite answer to that question. Atypical presentation of subarachnoid hemorrhage (SAH) with mild, or slowly progressive headache over minutes, and even absence of headache may occur in up to 3.8% of patients as reported in a recent Japanese study, but previously up to 10% has been reported. In a case series with 42 patients who had bled from an aneurysm, the headache came instantly in 50%, after 2-60 seconds in 24%, and within 1-5 minutes in 19%. In 10%-40% of patients with diagnosed bleeding from an aneurysm, there has been an episode with hyperacute headache prior to the one that led to the diagnosis. Such a warning leak has typically been reported to occur a couple of weeks earlier, but the risk of re-bleeding after SAH is highest within the first 24 hours. Non-ruptured aneurysms may also cause headache (dissection in the aneurysm wall, acute expansion or thrombosis), but more often they cause focal symptoms/signs due to mass effect Headache © 2019 The Authors. Headache: The Journal of Head and Face Pain doi: 10.1111/head.13650 published by Wiley Periodicals, Inc. on behalf of American Headache Society Published by Wiley Periodicals, Inc. ISSN 0017-8748