Worst Headache of Life: Evaluation of Nontraumatic Subarachnoid Hemorrhage

摘要

While the 'worst headache of life' has a differential diagnosis, acute subarachnoid hemorrhage must be the primary diagnostic consideration. Approximately l%-4% of patients presenting to the emergency department with severe headache have subarachnoid hemorrhage: (1) Subarachnoid hemorrhage is the number one secondary cause of incapacitating abrupt onset headache, while migraine headache is the number one primary cause: (2) There are approximately 30,000 cases of nontraumatic subarachnoid hemorrhage in the United States each year (2, 3). The classic presentation of nontraumatic subarachnoid hemorrhage is an acute onset, severe headache which reaches its maximum intensity within minutes, often referred to as the 'thunder clap' headache; (2) The headache is usual bilateral in nature and more often occipital than frontal. There may be associated neck stiffness, photophobia, nausea, vomiting and possibly obtundation or coma. Physical examination may show retinal hemorrhages, nuchal rigidity, or focal neurological signs. An altered level of consciousness is seen in approximately one third of patients while meningeal irritation signs are seen in up to 85% of patients and virtually all have nausea; (4) Retrospectively, a sentinel headache caused by a small subarachnoid hemorrhage or warning leak has been reported in 15% to 59% of patients before a major rupture of a saccular aneurysm; (5) Sentinel headaches usually persist for hours to days.