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The worst headache of your life.

November 13, 2009

Matthew Flaherty, MD

Everyone gets headaches from time to time. Headaches can occur from daily states of being such as stress, lack of sleep, or hunger, which usually go away when the state resolves. Others may have a specific type of headache such as migraine, cluster, or tension; these may be reviewed later. What might be concerning if one experiences the worst headache they have ever had in their life?

Subarachnoid hemorrhage is a type of bleed in the head that is caused when an artery in the brain ruptures and the blood, under high pressure, is forced into the subarachnoid space. To digress for a moment, the brain is covered by 3 layers called mater, the dura, which is the outermost layer, the arachnoid, which is the middle layer, and the pia, which is the layer directly covering the brain. The usual cause of a subarachnoid hemorrhage is a rupture of a brain aneurysm, or "bubble" that is protruding from the artery. Some may just be spontaneous rupture of an artery.

Subarachnoid hemorrhages can affect anyone, with the usual age range of 35-65 years. Smoking increased the risk of subarachnoid hemorrhage and is probably the most preventable cause. There is a high prevalence for those of younger age when recreational drugs such as crack or cocaine are involved. People with diseases such as congenital polycystic kidney disease (kidney problem), Type IV Ehlers-Danlos Syndrome (connective tissue disease), Fibromuscular dysplasia (arterial disease), has a higher incidence of having aneurysms in the brain than the general population. Also, there seems to be a greater risk of aneurysms in any individual, the more family members are affected.

Clinically, people will present to the emergency room with the, "worst headache of my life," or "thunderclap" headache. Classic presentations in medical textbooks are occuring during sex, strenuous exercise or going #2. Also, other symptoms are nausea and vomiting, neck stiffness, brief loss of consciousness, or seizures. There are times when people complain of a severe headache that lasts a few days and then goes away. This is known as a sentinel headache, and is usually a precursor of a catastrophic event.

Once in the emergency room, the easiest test to determine whether or not there is a subarachnoid hemorrhage is to get a noncontrast head CAT-Scan. Not getting a noncontrast head CAT-Scan is the most common reason subarachnoid hemorrhages are missed in the emergency room. If the CAT-Scan is negative and there is a high index of suspicion for subarachnoid hemorrhage, a lumbar puncture (spinal tap) should be performed. If both are negative, then the probability of a subarachnoid hemorrhage is low. Anyone found to have a subarachnoid hemorrhage with have a cerebral angiogram, which is the most definitive study.

Management depends of whether the subarachnoid hemorrhage was a result of an aneurysm or not. If an aneurysm is present, then the treatment will either be surgical clipping of the aneurysm or endovascular coiling of the aneurysm. The purpose of either is to fix the source of the bleeding. If there is no aneurysm, then medical management is the treatment.

1. If one has a headache that is so painful, get to the emergency room right away, as not all headaches are alleviated by over the counter pain medications.
2. Smoking cessation is crucial to decreasing the risk of having a subarachnoid hemorrhage.
3. Congenital polycystic kidney disease or any of the other diseases mentioned, or family members who have suffered subarachnoid hemorrhages as a result of an aneurysm, is a reason to get tested for possible aneurysm.
4. If in the emergency room and a CAT-Scan is not being done promptly, fight for your patient right to be treated fully as a subarachnoid hemorrhage is not something that can be missed by your physician.

1. Bederson JB et al. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. A Statement for healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association. Stroke. 2009; 40:1-20.
2. Ropper Allan, Samuels Martin. Spontaneous Subarachnoid Hemorrhage (Ruptured Saccular Aneurysm). Adam and Victor's Principles of Neurology. 2009; 34:808-816. on Social Media