A 49-year-old woman leans over the triage desk, one hand pressed to her temple, the other gripping her phone so tightly her knuckles blanch. She says the headache hit “like a gunshot” while she was folding laundry, and now the fluorescent lights make her eyes sting. Nausea keeps rolling through her, and she keeps asking for the curtain to be closed because the room feels too bright. She can answer questions, but every minute she looks more uncomfortable, and the monitor shows a blood pressure that is higher than you’d like. You have not yet decided whether this is just a bad migraine or something that will not wait.

— What’s your move? Read on.

Before you read
  • What is the one immediate management fork that changes everything?
  • Which medication buys time, and which intervention actually prevents rebleeding?

When to Think of It

Thunderclap headache reaching maximal intensity in seconds to minutes, especially with exertional onset, vomiting, meningismus, photophobia, syncope, seizure, or transient loss of consciousness. Enter this diagnosis early even if the neuro exam is normal.

Sick or Not Sick

The single call: is she neurologically intact and hemodynamically stable enough for urgent imaging/transfer, or is she deteriorating and needs airway/ICP-focused resuscitation now? Hunt-Hess/WFNS severity matters, but the practical fork is “can she protect brain perfusion and get to definitive aneurysm care safely?”

The First Fifteen Minutes

  • Severe pain, vomiting, agitation → fentanyl 25–50 mcg IV q5–10 min PRN for analgesia; ondansetron 4–8 mg IV for emesis, because pain/vomiting spike BP and ICP.
  • SBP persistently elevated (commonly >160 mm Hg while aneurysm unsecured) → nicardipine 5 mg/h IV, titrate by 2.5 mg/h every 5–15 min (max 15 mg/h) or clevidipine 1–2 mg/h IV, double every 90 sec initially to effect because controlled reduction lowers rebleed risk without crashing CPP.
  • Concern for seizures or witnessed seizure → levetiracetam 1,000–1,500 mg IV now (then maintenance per protocol), because early seizure worsens ICP and oxygen demand.
  • If declining mental status, aspiration risk, or inability to protect airway → rapid sequence intubation with induction/paralysis per your usual ED protocol, because hypoxia/hypercarbia rapidly worsen cerebral blood flow and ICP.
  • Suspected raised ICP with impending herniation → hypertonic saline 3% 2–3 mL/kg IV bolus (or institutional equivalent) because osmotic therapy can transiently lower ICP.
  • If hypotensive or volume depleted → isotonic crystalloid bolus (e.g., 500–1,000 mL normal saline) because cerebral perfusion is pressure dependent; avoid hypotonic fluids.

Definitive Care & Disposition

Noncontrast head CT first; if negative but suspicion remains high and timing is appropriate, proceed to LP or CTA per local pathway and risk tolerance. Once diagnosed, give nimodipine 60 mg PO/NG q4h as early as possible if enteral route is available, because it reduces delayed ischemic deficits. Neurosurgery/neurocritical care consultation is mandatory; transfer to a center with aneurysm coiling/clipping if not available. Admit to ICU or neuro-ICU; unsecured aneurysm = close BP control, frequent neuro checks, and expedited aneurysm occlusion.

How This One Kills

The catastrophic failure is treating it like a benign headache and missing the unsecured aneurysm—the patient rebleeds in the hours after discharge or during a blood pressure surge, often before definitive care is reached.
The Differential — What Else Looks Like This
  • Migraine — usually has a recurrent pattern, aura/photophobia history, and slower escalation; confusing it with SAH misses the rebleed window.
  • Meningitis — fever and infectious prodrome point away; confusing it delays aneurysm imaging and BP control.
  • Cervical artery dissection — neck pain or focal deficit may dominate; missing SAH means chasing the wrong vascular lesion.
  • Sentinel headache / benign thunderclap — CT can be negative early; assuming benignity without follow-up workup risks missing the leak before rupture.

The Second-Day Story

Older patients, patients with limited pain expression, and those who present late may not volunteer “worst headache of life.” Some have only sudden occipital pain, vomiting, neck pain, or brief collapse; others are nearly neurologically intact except for photophobia or a markedly unusual headache. If the story sounds abrupt and maximal at onset, do not let a normal exam or mild improvement after analgesia reassure you out of the diagnosis.
Back to Our Patient
Back to our 49-year-old woman with the lightning-onset headache and photophobia: this is aneurysmal subarachnoid hemorrhage until proven otherwise. She needs emergent noncontrast head CT, BP control with nicardipine if SBP remains high, antiemetic and analgesia to blunt ICP surges, and urgent neurosurgery/neurocritical care involvement for aneurysm securing. If the CT is negative but suspicion remains high, the workup continues rather than stopping at “migraine.” She goes to ICU-level care and definitive aneurysm management, not home.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“49-year-old woman with sudden severe headache that began explosively while folding laundry, now with photophobia and nausea, no prior similar headaches, and no focal weakness or trauma. She’s alert but very uncomfortable, with a nonfocal neuro exam and BP 178/96. I’m concerned for aneurysmal subarachnoid hemorrhage. I’ve kept her NPO, started antiemetic and analgesia, and I’m getting an emergent noncontrast head CT now with neurosurgery alerted. If CT is negative and suspicion remains, I’ll pursue the next diagnostic step rather than stopping.”

Study Directive

  • Draw the SAH workflow from memory: thunderclap headache → CT → LP/CTA if needed → BP control → nimodipine → ICU/neurosurgery.
  • Practice three “can’t miss” opening questions for sudden headache: onset timing, maximal intensity timing, and associated collapse/vomiting/neck stiffness.
  • Memorize nimodipine dosing and one alternative BP infusion each for neuro-bleed patients.
  • Review 5 CT/LP decision pathways and decide when your shop uses LP versus CTA after negative CT.

Recent Literature