The patient presenting with the classically described acute onset of severe headache that is described as “worst ever,” with a time to peak of seconds and associated nausea, vomiting, and focal deficits is typically a candidate for sSAH workup. Evaluation of the alert patient with a normal neurologic examination or one with a vague change in his or her primary migraine disorder is less clear. Most worstof- life headaches treated in the ED will have benign causes. Approximately 10% to 16% will have serious pathology, including but not limited to sSAH.61-66
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