A fictional 45-year-old develops a sudden severe headache that reaches maximum intensity within seconds, with vomiting and neck stiffness.
Frame the danger first.
- Thunderclap onset is a time-critical red flag until serious secondary causes are excluded.
- Record the exact onset time, neurological symptoms, anticoagulant use and relevant family history.
- Assess consciousness, pupils, focal deficit and meningism while resuscitation principles run in parallel.
Act, escalate, reassess.
- Use the local acute-headache or suspected-subarachnoid-haemorrhage pathway and obtain urgent senior review.
- Arrange urgent non-contrast CT head as directed by the current pathway; do not delay for non-essential tests.
- If initial imaging does not resolve the concern, involve the appropriate acute neurology/neurosurgical pathway for further investigation.
- Provide analgesia and antiemetic treatment while monitoring for deterioration.
Red flags that change pace.
- Reduced consciousness, seizure, focal neurological deficit or worsening headache
- Sudden onset during exertion, neck stiffness, persistent vomiting or visual symptoms
- Anticoagulation, significant hypertension or a known aneurysm/vascular-risk history
What makes care less safe.
- Calling a first thunderclap headache migraine without urgent assessment
- Failing to document onset timing
- Using one investigation result without interpreting it in relation to timing and clinical suspicion
Say the concern plainly.
Possible subarachnoid haemorrhage: thunderclap headache began at [exact time], with [neurological/meningeal features]. Observations and examination are [summary]; CT and senior pathway actions are [status].