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Station 09: Severe Headache
Emergency neurology station for thunderclap headache, red flags, SAH/meningitis/stroke differential, urgent imaging, and disposition.
Neurology / EmergencyAssessment + Emergency Management11-minute encounter2-minute reading prompt
Door prompt
You are in the emergency department. A 42-year-old patient presents with the worst headache of their life that started suddenly 2 hours ago. Take a focused history, verbalize examination, and outline immediate management.
Candidate tasks
- Assess immediate stability and neurologic red flags.
- Take a focused severe headache history.
- State relevant neurologic and systemic examination.
- Give differential diagnosis, urgent investigations, management, and disposition.
Exam discipline: Do the station first. Open the checklist only after completing your attempt.
Opening script
A sudden severe headache can sometimes represent a serious condition, so I will ask focused questions, examine your nervous system, and arrange urgent tests while treating your pain and nausea.
Critical safety point
Thunderclap headache is subarachnoid hemorrhage until proven otherwise. Do not discharge a patient with sudden worst headache without appropriate urgent assessment.
Focused history framework
- Onset: sudden vs gradual, time to peak intensity, activity at onset, exertion/sex/cough trigger.
- Headache character, location, severity, radiation, duration, previous similar headaches.
- Associated symptoms: vomiting, neck stiffness, photophobia, fever, loss of consciousness, seizure.
- Neurologic symptoms: weakness, numbness, diplopia, vision loss, speech difficulty, ataxia, confusion.
- Risk factors: hypertension, anticoagulants, bleeding disorders, pregnancy/postpartum, cocaine/stimulants.
- Infection risks: immunosuppression, recent infection, rash, travel.
- Trauma history and cervical artery dissection symptoms: neck pain, Horner syndrome, recent manipulation.
- Medication history, allergies, migraine history, family history of aneurysm/SAH.
Focused physical examination to verbalize
- ABCs, vitals, level of consciousness, pain severity.
- Full neurologic examination: cranial nerves, power, sensation, reflexes, coordination, gait if safe.
- Meningeal signs: neck stiffness, photophobia; look for rash or sepsis signs.
- Fundoscopy if feasible for papilledema or retinal hemorrhage.
- Cardiovascular exam and blood pressure assessment.
- Head/neck exam for trauma, temporal artery tenderness when age/context suggest, and cervical dissection signs.
Diagnosis, investigations, and management
| Area | Expected content |
|---|---|
| Most concerning diagnosis | Subarachnoid hemorrhage is a critical concern with thunderclap worst headache reaching peak intensity rapidly. |
| Differentials | Meningitis/encephalitis, intracerebral hemorrhage, ischemic stroke, cerebral venous thrombosis, cervical artery dissection, hypertensive emergency, migraine, cluster headache, temporal arteritis depending age/features. |
| Immediate investigations | Urgent non-contrast CT head, ECG/vitals, CBC/electrolytes/coagulation if indicated, pregnancy test when applicable. Further CTA/LP pathway depends on CT timing, local protocol, and suspicion. |
| Initial management | Analgesia, antiemetic, IV access, monitor neurologic status, treat severe hypertension carefully if indicated, keep NPO if neurosurgical intervention possible. |
| Consult/disposition | Neurology/neurosurgery or emergency specialist involvement. Admit/observe for confirmed or strongly suspected serious secondary headache. |
| Meningitis branch | If fever, meningismus, altered mental status, or sepsis suggests meningitis, give empiric antimicrobials promptly after appropriate cultures when this does not delay treatment. |
Standardized patient information and likely findings
- Headache reached maximum intensity within one minute while lifting boxes.
- Patient vomited once and has neck stiffness.
- No previous migraine of this intensity.
- No trauma. Patient has hypertension and missed medication recently.
- Patient asks for strong pain medicine and wants to go home if CT is normal.
Oral questions and model answers
| Examiner question | Strong answer |
|---|---|
| What is the key diagnosis you must exclude first? | Subarachnoid hemorrhage, because sudden thunderclap worst headache is high risk even if initial examination is not dramatically abnormal. |
| What is your first imaging test? | Urgent non-contrast CT head, with further testing such as CTA or lumbar puncture depending timing, local pathway, CT result, and ongoing suspicion. |
| Can the patient go home if pain improves after analgesia? | Not until serious secondary causes have been appropriately assessed; symptom improvement does not exclude SAH or meningitis. |
| What features suggest meningitis? | Fever, neck stiffness, photophobia, altered mental status, rash, immunosuppression, or sepsis features. |
Self-scoring checklist
Your checklist score
Tick only items you clearly performed.
0 / 0 0%
Checklist items
- Recognized thunderclap headache as emergency.
- Asked time of onset and time to peak intensity.
- Asked activity/trigger at onset.
- Asked severity and “worst headache” comparison.
- Asked vomiting, neck stiffness, photophobia, fever.
- Asked loss of consciousness or seizure.
- Asked focal neurologic symptoms.
- Asked trauma and neck pain/dissection features.
- Asked anticoagulant use and bleeding risk.
- Asked hypertension, stimulant/cocaine use, pregnancy/postpartum when relevant.
- Asked migraine history and prior similar headaches.
- Verbalized vitals and level of consciousness.
- Verbalized full neurologic exam.
- Verbalized meningeal signs and rash/sepsis assessment.
- Identified SAH as critical diagnosis.
- Provided broad serious differential.
- Ordered urgent non-contrast CT head.
- Considered CTA/LP pathway if CT negative but suspicion remains.
- Provided analgesia and antiemetic.
- Arranged monitoring and specialist consultation.
- Did not discharge based only on improved pain.
- Explained seriousness while maintaining reassurance.
High-yield feedback after the station
What earns marks
- Treating thunderclap headache as SAH until proven otherwise.
- Clear neurologic and meningeal examination.
- Urgent imaging pathway and no premature discharge.
- Balanced communication: serious but not panic-inducing.
Common pitfalls
- Diagnosing migraine too early.
- Failing to ask time to peak intensity.
- Letting pain improvement drive disposition.
- Ignoring meningitis, dissection, venous thrombosis, or hypertensive emergency.