Clinical Case 131: the Latent Lover’s Headache

Hi there.  Just back from a great break in beautiful Vanuatu.  Seriously amazing place to visit and explore.  The beauty: death ratio is in balance!

I have a case for you today which has come up a few times recently.  It is certainly something that does occur in the ED, but most GPs deal with this dilemma on a regular basis.  Let us dive right in.

Our patient is a 28 year old chap – lets call him Trent.  Trent works in the local sausage factory as a quality control supervisor.  He is usually fit and healthy with no real family history or chronic problems.  He does a bit of exercise, doesn’t smoke and has a few beers at the weekends.  Trent has recently gotten married and life is sweet.

You are working away in your busy GP rooms – Trent is your next patient.  You last saw him for some travel immunisations prior to his honeymoon.  He is a very infrequent attender to your practice…

Here is how the consult goes:

Dr: Hi Trent, hows things?

T: Well Doc.  I’m OK.  My wife has told me I need to come and ask about this headache I got the other day.  I’m not too worried though…

Dr: tell me about it.

T:  Well its a bit embarrassing.  We were sort of fooling around – you know.  Getting intimate.  And half way through I got this sudden headache.  It was like somebody whacked me over the ear with a cricket bat.  It was really full on! One second I was fine, then I was almost knocked out.  Could hardly think.  I was rolling on the floor in pain for half an hour.  It felt like my  head was gonna explode.  Everything was a bit grey for the rest of the night

Dr: Wow. That sounds bad.  When was this. what happened?

T: Oh it happened 2 nights ago. About 48 hours I guess.  The pain eased off a bit after half an hour, but it was still there when I woke up the next day.  I was feeling rubbish and took the day off work.  It went away over the day – so I didn’t bother going to the ED.  But Sheila thought I should get a check up…. just in case.

                  OK, Freeze it there.

Think about how you would approach this case if you were working in ED and Trent presented immediately after the headache began – say 2 hours.

Now put yourself in a GP clinic 2 days later, he is now essentially asymptomatic, with a normal set of Obs, Neuro exam and really seeking reassurance.

What to do?

Here are my questions for you….

Q1:  Does Trent need a work up for subarachnoid haemorrhage / other malignant brain / vascular problems? i.e.  should he get imaging +/- LP today?

Q2:  Does the fact that he is now well, asymptomatic and alive decrease the odds that he has a SAH?

Q3:  If he told you that the headache started immediately after orgasm, rather than in the earlier phase of coitus, would it change your approach?

And just because I am a nice bloke I will add this image to help you visualise the relative usefulness of the investigations for SAH over time.  BEWARE: this is based on some seriously good and some not so good literature [and the graph may not be entirely to scale!!]

Sensitivity of Ix for SAH vs Time
Sensitivity of Ix for SAH vs Time
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