Thunderclap Headache and Other Headaches Presenting in the Emergency Department

Equally important is the patient presenting with an acute headache and new-associated neurologic symptoms, particularly focal motor or sensory loss, language dysfunction, or encephalopathic symptomatology, such as confusion or seizures. Other historical details in the acute headache patient also cause significant concern warranting further and immediate evaluation. These include older age, immunocompromise, recent infection or fever, history of cancer, clotting or bleeding disorders (particularly including therapeutic anticoagulation), progressively worsening headache severity, or symptoms of systemic illness, that is, weight loss, fatigue, myalgia, or unexplained anemia.

Any patient whose clinical presentation with headache includes fever, alteration in consciousness or mentation, or an overall toxic appearance requires an urgent evaluation for a possible underlying infection. Nuchal rigidity usually indicates meningeal irritation, which can be seen with either subarachnoid hemorrhage or meningitis. Papilledema reflects increased intracranial pressure and warrants further investigation for disorders causing mass effect, such as tumor, infection, hemorrhage, or idiopathic intracranial hypertension.

SUBARACHNOID AND INTRAPARENCHYMAL HEMORRHAGE

Although the classic thunderclap presentation typically heralding the rupture of an intracerebral aneurysm with subarachnoid hemorrhage (SAH) is not easily overlooked, occasional SAH patients present with more subtle symptoms. Any headache that is unusual for the patient, especially if there is associated neck pain or stiffness, needs to lead the clinician to question the possibility of SAH. Intraparenchymal hemorrhage is more likely to cause relatively rapid evolution of focal neurologic symptoms as well as seizures and altered mentation, depending on the size and location of the hematoma. If the blood tracks into the cerebrospinal fluid (CSF), intraparenchymal hemorrhage may also cause meningeal irritation and neck stiffness. A history of anticoagulation, especially in an older patient presenting with headache is particularly concerning for hemorrhage. A computed tomography (CT) scan is diagnostic. Information on evaluation and management of intracranial hemorrhage is detailed in Section 9.

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