Acute neck pain, an atypical presentation of subarachnoid haemorrhage

Subarachnoid hemorrhage mimicking an acute migraine attack: A case report

Subarachnoid hemorrhage is a neurological emergency in which arterial blood accumulates in the subarachnoid space with cerebral aneurysmal rupture being the most common cause. Subarachnoid hemorrhage is often misdiagnosed in the emergency department and mortality rates range from 8% to 67%. It may be the manifestation of the chronicity of the migraine. The difference in severity or quality compared to previous headaches, and other symptoms, particularly neck stiffness, but also seizure, syncope, focal neurological deficit, and vomiting are the key factors differentiating subarachnoid hemorrhage from the migraine. We report a case of a 37-year-old female with a previous history of migraines who presented with acute onset of excruciating headaches in the occiput associated with nausea, vomiting, and photophobia in whom a non-contrast computed tomography scan of the head showed hyper-densities involving the bilateral cerebral cortical sulcus and Sylvian fissure and the cerebral angiography showed a complex aneurysm in anterior communicating artery.

Applying the Ottawa subarachnoid haemorrhage rule on a cohort of emergency department patients with headache

OBJECTIVE

The Ottawa subarachnoid haemorrhage (SAH) rule suggests that alert patients older than 15 years with a severe nontraumatic headache reaching maximum intensity within 1 h and absence of high-risk variables effectively have a SAH ruled out. We aimed to determine the proportion of emergency department (ED) patients with any headache fulfilling the entry criteria for the Ottawa SAH rule.

PATIENTS AND METHODS

The Ottawa SAH rule was applied retrospectively in a substudy of a prospective snapshot of 34 EDs in Queensland, Australia, carried out over 4 weeks in September 2014. Patient aged 18 years and older with a nontraumatic headache of any potential cause were included. Clinical data and results of investigations were collected.

RESULTS

Data were available for 644 (76%) patients. A total of 149 (23.1%, 95% confidence interval: 20.0-26.5%) fulfilled and 495 (76.9%, 95% confidence interval: 73.5-80.0%) did not fulfil the entry criteria. In patients who fulfilled the entry criteria, 30 (<5% overall) did not have any high-risk variables for SAH. In patients who fulfilled the entry criteria and had at least 1 high-risk feature, almost half (46%) received a computed tomographic brain. No SAH were missed.

CONCLUSION

In this descriptive observational study, the majority of ED patients presenting with a headache did not fulfil the entry criteria for the Ottawa SAH rule. Less than 5% of the patients in this cohort could have SAH excluded on the basis of the rule. More definitive studies are needed to determine an accepted benchmark for the proportion of patients receiving further work-up (computed tomographic brain) after fulfilling the entry criteria for the Ottawa SAH rule.