What is the appropriate management for a 28-year-old male with no history (hx) of headaches presenting with a left-sided headache (HA), described as the worst of his life, ongoing for 3 days, without fever, neck stiffness, or injury?

Immediate Neuroimaging Required

This patient requires urgent neuroimaging (CT or MRI) before any treatment is initiated, as a "worst headache of life" in a patient with no prior headache history represents a red flag for secondary causes including subarachnoid hemorrhage, intracranial mass, or other life-threatening pathology. 1, 2, 3

Critical Red Flags Present

This presentation contains multiple concerning features that mandate immediate investigation:

• New onset headache in a patient with no prior headache history - This alone warrants neuroimaging, as the absence of a baseline headache pattern makes secondary causes more likely 4, 2

• "Worst headache of life" - This classic descriptor is the hallmark of subarachnoid hemorrhage and other catastrophic intracranial events, requiring immediate exclusion 1, 2, 3

• Duration of 3 days without resolution - A new, persistent headache that continues for days suggests a progressive process rather than a self-limited primary headache disorder 1, 2

• Age and demographics - While 28 years old is within the typical age range for migraine onset, the combination of age with other red flags increases concern for secondary causes 2, 3

Diagnostic Approach

Neuroimaging is the mandatory first step - Either CT head (if immediate availability) or MRI brain (preferred for sensitivity) must be obtained before symptomatic treatment 4, 2, 3:

• CT without contrast is appropriate for initial evaluation to rule out hemorrhage, mass effect, or acute hydrocephalus 2
• MRI with and without contrast provides superior sensitivity for subtle pathology including venous sinus thrombosis, posterior circulation stroke, or small masses 2
• If neuroimaging is normal but clinical suspicion remains high, lumbar puncture may be necessary to exclude subarachnoid hemorrhage (particularly if >6 hours from onset when CT sensitivity decreases) or meningitis 2

Why Treatment Should Wait

The conservative approach mandates neuroimaging before initiating migraine-specific therapy in patients with neurologic symptoms or atypical features 4:

• Treating empirically as migraine could mask evolving neurologic deterioration from a secondary cause 1, 5
• The absence of fever and neck stiffness does not exclude serious pathology - many intracranial processes present without these findings 2, 3
• A normal neurologic examination does not eliminate the need for imaging when red flags are present 4, 2

Common Pitfall to Avoid

Do not assume this is migraine based solely on unilateral location and severity - While migraine can present as severe unilateral headache, the "worst of life" descriptor in a patient with no headache history is subarachnoid hemorrhage until proven otherwise 1, 2, 3. The 3-day duration makes thunderclap SAH less likely but does not exclude other serious causes such as cerebral venous thrombosis, mass lesion, or idiopathic intracranial hypertension 2, 3.

After Imaging is Clear

Only after neuroimaging excludes secondary causes should acute migraine treatment be considered 4, 6:

• First-line acute treatment: NSAIDs (ibuprofen 400-800mg or naproxen 500-1000mg) or combination therapy with aspirin 250mg + acetaminophen 250mg + caffeine 65mg 6
• For moderate-to-severe pain: Triptans (sumatriptan 50-100mg orally, or 6mg subcutaneous for fastest relief) 6
• If nausea present: Add metoclopramide 10mg or prochlorperazine 10mg 6
• Avoid opioids: These lead to dependency, rebound headaches, and loss of efficacy 6

Disposition

If imaging is normal, the patient should be referred to neurology or a headache specialist for proper classification of the headache disorder and consideration of preventive therapy if attacks recur 5, 7.