CHAPTER 13 SUBARACHNOID HEMORRHAGE
2. A 40-year-old woman in the emergency department complains of the worst headache of her life that has its onset during sexual intercourse. On examination, she is slightly sleepy and has a stiff neck but no other signs. What diagnosis should be considered?
This is a classic story for subarachnoid hemorrhage. The sudden onset of “the worst headache of my life” is the tipoff. Most commonly, it occurs during the Valsalva maneuver—while straining at stool or during sexual intercourse. Patients commonly demonstrate stiff neck and some alteration of level of consciousness. The absence of localizing signs on neurologic exam does not contradict the diagnosis. A few specific types of subarachnoid hemorrhage will include localizing signs (see Question 3).
