A patient presents with a sudden severe headache described as the worst headache of life, photophobia, and neck stiffness. What is the most likely diagnosis and initial management?

• A. Subarachnoid hemorrhage; emergent CT head and, if negative, LP; neurosurgical evaluation.
• B. Migraine with aura; treat with analgesics.
• C. Tension-type headache; NSAIDs and rest.
• D. Intracerebral hemorrhage; MRI.

Answer: (A)

Sudden, severe headache described as the worst of life, with photophobia and neck stiffness, strongly suggests subarachnoid hemorrhage from ruptured aneurysm causing meningeal irritation. The first step is emergent noncontrast CT of the head, because it rapidly detects subarachnoid blood early on and directs urgent care. If the CT is negative but the clinical picture remains highly suspicious, proceed with lumbar puncture to look for red blood cells or xanthochromia in the CSF, which would confirm SAH. Once SAH is diagnosed or highly suspected, immediate neurosurgical evaluation is essential for securing the aneurysm—via clipping or endovascular coiling—to prevent rebleeding, along with intensive supportive care. Early management also focuses on stabilizing the patient, controlling blood pressure to reduce rebleed risk, and addressing vasospasm risk after SAH (for example, with nimodipine). The other headache types don’t fit this presentation: migraines with aura usually lack neck stiffness and are not typically maximal in onset, tension-type headaches are generally milder and without meningeal signs, and intracerebral hemorrhage typically presents with focal neurologic deficits rather than diffuse meningeal irritation.