A 38-year-old man presents to the emergency department with sudden onset of a severe frontal headache (HA) beginning two hours earlier while at work. He is feeling nauseated but hasn’t vomited. There was no loss of consciousness, fever, or neck pain. He reports that it feels like his previous tension HA, but it did not resolve with ibuprofen this time. His physical examination is normal.
Headaches represent around 2 percent of emergency department visits each year. Of these presentations, 1 to 3 percent turn out to be a subarachnoid hemorrhage (SAH).1–3
There are other causes of sudden onset of headache besides migraine and SAH. These include cough, exertion, and sexual intercourse (postcoital) as well as potentially life-threatening conditions like sinus thrombosis, vascular dissection, intracerebral hemorrhage, vasospasm, and aneurysmal subarachnoid hemorrhage.4–7