I experienced a sudden severe headache and a rapidly developing rash on my neck while lifting very heavy weights; what should I do?

Immediate Emergency Evaluation Required

You must seek emergency medical care immediately—this presentation of sudden severe headache with rapidly developing rash during heavy lifting is a medical emergency requiring urgent evaluation for subarachnoid hemorrhage, which can present with exertional onset and associated skin changes from autonomic dysfunction. 1, 2

Critical Red Flags Present

Your presentation contains multiple features that mandate immediate emergency department evaluation:

• Exertional onset during heavy lifting is one of the criteria that mandates additional investigation for subarachnoid hemorrhage 1
• Sudden severe headache reaching peak intensity rapidly is the hallmark presentation of subarachnoid hemorrhage, occurring in 74% of confirmed cases 2
• Rapidly developing rash on the neck may represent autonomic dysfunction or associated vascular pathology requiring urgent assessment 3, 4
• Combination of headache with systemic signs (the rash) requires immediate CT imaging 4

Immediate Diagnostic Workup Required

Upon arrival at the emergency department, you should receive:

• Non-contrast head CT within 6 hours of symptom onset, which has 98.7% sensitivity for subarachnoid hemorrhage and remains the cornerstone of diagnosis 1, 2
• If CT is negative but clinical suspicion remains high, lumbar puncture must be performed >6-12 hours after symptom onset to evaluate for xanthochromia (sensitivity 100%, specificity 95.2%) 1, 2
• CT angiography should be considered to evaluate for vascular pathology including arterial dissection if initial workup is inconclusive 1
• Thorough neurological examination looking for focal deficits, meningismus, altered consciousness, or cranial nerve palsies 1

Why This Cannot Wait

The combination of exertional headache with systemic manifestations creates several life-threatening possibilities:

• Subarachnoid hemorrhage carries a 3-4% rebleeding risk in the first 24 hours, rising to 17% when blood pressure is elevated 2
• Sentinel bleed from an aneurysm can present with exertional onset before catastrophic rupture 5
• Cardiac ischemia can present as exertional headache with autonomic symptoms 1, 6
• Meningitis requires immediate emergency department evaluation via ambulance and consideration of lumbar puncture 4

Critical Pitfall to Avoid

Never assume a new exertional headache is benign without proper imaging—missing subarachnoid hemorrhage carries catastrophic consequences, and failure to obtain neuroimaging is the most common diagnostic error in subarachnoid hemorrhage 1, 2

Transport Instructions

• Do not drive yourself—arrange emergency ambulance transport so you arrive within one hour of assessment 3
• Maintain blood pressure control if possible, as elevated systolic BP >150-160 mmHg increases rebleeding risk 2
• Document the exact time of headache onset and any associated symptoms including loss of consciousness, neck stiffness, or neurological changes 1, 2

If Imaging Is Negative

Only after life-threatening causes are excluded through appropriate imaging and potentially lumbar puncture can benign exertional headache be considered. Primary exertional headache is a diagnosis of exclusion that requires thorough neurologic evaluation and imaging studies to eliminate secondary causes 5. However, the rapidly developing rash makes a purely benign exertional headache less likely and increases concern for systemic pathology 4.