Worst headache of her life yesterday — thunderclap history
PLAB 2 & PRES 3 · neurology · hard · 8 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mrs Sarah Linden, 34, has booked an urgent appointment about a severe headache she had yesterday evening, which has now completely resolved. She feels well today. Take a focused history of the headache and discuss your assessment and management plan with her.
What examiners look for
A thunderclap headache reaches maximum intensity within about a minute of onset. It is a presentation, not a diagnosis, and subarachnoid haemorrhage is the cause that must be excluded first, even when the pain has completely resolved. Headache resolution does not equal safety. A small "sentinel" or warning leak from an aneurysm may stop hurting and still precede a major rupture days later — which is why the timing of presentation does not downgrade the urgency. The differential for thunderclap headache includes reversible cerebral vasoconstriction syndrome, cervical artery dissection, cerebral venous thrombosis, pituitary apoplexy, meningitis (if febrile), and a first severe migraine — migraine is a diagnosis of exclusion here, not a starting assumption. Ask the onset question precisely: "How long did it take to reach its worst?" Migraine typically builds over minutes to hours; a headache that is maximal in seconds is a different animal. The combined oral contraceptive pill matters in the background (relevant to venous thrombosis risk), as do anticoagulants — always complete the drug history in headache stations. A normal neurological examination does not exclude subarachnoid haemorrhage. The assessment that matters is urgent hospital imaging and specialist input, arranged the same day. Explanation is a scored skill in this station: the patient feels well and slightly foolish for attending. Candidates do best when they validate her decision to come, explain the concern in plain words, and avoid both alarmism and false reassurance. Safety-netting must be specific: return of the sudden headache, vomiting, drowsiness, limb weakness, speech disturbance or seizure means call 999 immediately — not "see how it goes".
Guideline references
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