Neuroscience Clerkship

 

 

Headache of Subarachnoid Hemorrhage

 

The hallmark of SAH is a sudden onset, severe headache. Patients usually describe it as the “worst headache of my life”, and the character is unlike any prior HA the patient has experienced. The headache is explosive, reaching a maximum within seconds. This is in contradistinction to migraine, which even if very severe, typically builds up over 5-30 minutes. The headache is usually generalized, constant, not relieved by anything, and non-positional. Other signs of meningeal irritation may be present, including neck stiffness, fever, nausea/vomiting, and fluctuating level of consciousness. Sudden, transient loss of consciousness may accompany the headache in nearly half of patients. The absence of focal neurologic symptoms with sudden onset headache is the classic description of SAH, however, focal deficits may occur.

There may be milder “sentinel headaches” which occur in the weeks prior to SAH due to small leaks of an aneurysm; these are also sudden onset headache and may occur in any location.

The headache of SAH is often described as severe and sudden, similar to a loud "thunderclap". Although SAH is characteristically associated with a thunderclap headache, rarely, other disorders may present in the same way, some which are benign and others that signify serious intracranial pathology.