Is It More Than Just a Migraine?

A 42-year-old woman with a history of

_____________ headaches presents to
the emergency department (ED) for
evaluation of a _________. She states that
this headache is different than the

u
migraines she typically experiences. The

h
pain onset is more rapid with ______

et
occurring earlier in the headache course
than is usual for her. The location of the
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pain is also atypical for her: it is both
_____________ as opposed to being
i th
primarily frontal. She has no difficulty with
______, __________, or __________; she
has no fever, ___________, or other
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complaints.
Her vital signs are normal except for a
pulse of _____________ and blood
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pressure (BP) of 147/91 mm Hg. The only

physical examination finding of note is
_____________. Initial diagnostic tests
include a complete _____________ and
basic _____________; findings from these
tests are within normal ranges. A
_____________ (CT) scan of the patient’s
head is also taken.
_______________ (SAH) is a rare but life-
threatening cause of headache. The
incidence of SAH peaks in _________

u
_____________. Clinical presentation of

h
SAH varies significantly depending on

et
severity — from sudden onset headache
without other symptoms to _______

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____________.Headache may be
accompanied by _______ and/or _______,
stiff neck, _____________, brief loss of
i th
_____________, or focal neurological
deficits such as _______________.
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The challenge is deciding which patients

require CT scans to diagnose SAH without
scanning the larger population of patients
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who present with ________, _______

__________, and other benign conditions.
Patients with migraines are particularly
challenging because they may also
present with vomiting and photophobia.
However, a migraine should immediately
be put to the bottom of the list of ________
__________ in a patient who is having
________ not previously experienced with
their migraines.
Clinical decision tools such as the Ottawa
SAH Rule may provide some guidance,
but many unnecessary CT scans may still
be performed when using this tool.The

u
most important “_______” for SAH is a

h
peak in pain within minutes of headache

et
onset and that is different from prior
headaches.

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The manner of asking questions to
determine if the headache is truly ______
i th
at onset is important and part of the _____
__________. If clinicians ask “did the
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headache start ___________?” they will

end up ordering a lot more unnecessary
head CTs than if they had asked “is the
headache still ___________?” or “how
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many hours did it take for the headache to

reach ___________, or is it still ________
________?”
When a head CT scan is ordered and
performed within _________ of headache
onset, the sensitivity for SAH has been
reported to be _____________ for all
patients, which typically obviates the need
for _____________(LP).However, an LP
should be performed early if there is a
clinical concern for meningitis, which can
also present with sudden onset headache,
or the patient has considerable risk factors
for SAH . An LP should also be performed
if CT is performed more than 6 hours after
pain onset or is not definitive due to
scanner generation or because the patient

u
has anemia.

h
et
Management of confirmed SAH in the ED
includes neurosurgical consult; _________
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the head of bed to 30°; treatment with
_____________ medications to
maintaining systolic BP less than 140 mm
i th
Hg to prevent stroke; and administering
_____________, a calcium channel
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blocker, to improve neurologic outcomes.

Other treatment should be directed by the
neurosurgeon and includes __________
_________ or coiling the aneurysm in the
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majority of cases.