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An ambulance brings a 39-year-old woman complaining of a severe occipital headache and vomiting from her workplace to the emergency department (ED). She describes the headache as “the worst ever headache of my life” and states that it started suddenly, after a stressful situation at work. The intensity of the headache did not diminish after taking 200 mg of ibuprofen. She denies any head trauma, intense physical exertion, fever, changes in vision, photophobia, or any other associated symptoms (other than vomiting). She mentions that 2 days before presentation, she had a headache of similar intensity, but it only lasted a few seconds before resolving spontaneously. Her medical history is remarkable for 2 normal pregnancies with uncomplicated deliveries. She denies any prior surgeries, and her only medications are oral contraceptives, which she has taken for about 15 years. She works as a dressmaker and denies illicit drug use, tobacco use, or alcohol consumption. She does not recall any significant medical problems in her family history.

On physical examination, she is obese and appears her stated age. She is in mild distress due to pain. Her axillary temperature is 97.8°F (36.6°C). Her pulse is regular at 78 bpm, her blood pressure is 160/80 mm Hg (which she states is high for her), and her respiratory rate is 20 breaths/min. Her head is normal on inspection, without any areas of tenderness. The ears, nose, and throat are clear. Her pupils are both small at 2 mm, but they are reactive to light. Otherwise, the eyes appear normal, with normal extraocular movements and no photophobia or nystagmus. The fundi and optic discs appear normal. No masses are detected on examination of her neck, but significant nuchal rigidity is noted. The chest examination is normal, with lungs clear to auscultation bilaterally and normal respiratory effort. The heart sounds are also normal. Her abdomen is soft and nontender. The neurologic examination reveals that she is fully alert, oriented, and mildly anxious. Her cranial nerves are intact. Motor strength is symmetrical, with brisk and symmetric deep tendon reflexes without clonus. Cerebellar function and sensory systems are normal.

Laboratory analyses, including a complete blood count, metabolic panel, and urine analysis, are normal. A noncontrast cerebral computed tomography (CT) scan is performed (Figure 1).

What is the diagnosis?

Hint: The patient has no prior history of similar headaches.

Migraine headache

Subarachnoid hemorrhage

Meningitis

Vertebral artery dissection

Cerebral venous sinus thrombosis