A 46-year-old man with no prior headache felt something burst in his head while lifting. The pain reached the worst of his life in under a minute. He is nauseated. The neurological examination at this moment is normal, and he has no fever.
A relative suggests migraine, because his sister has it.
What is the first step?
This is a thunderclap pattern and is subarachnoid haemorrhage until proven otherwise. A normal examination does not exclude it. The path is emergency care and immediate imaging by the hospital protocol, not a migraine prescription and discharge.
A sister with migraine does not lower the risk of this onset. Migraine can be severe, but peaking within seconds to one minute is not ordinary migraine.
This is a teaching vignette and refers to no identifiable patient. These pages are written for health professionals. They do not replace a history, examination, or clinical judgment. Treatment is decided for each patient individually.