Subarachnoid Hemorrhage vs Migraine
Subarachnoid Hemorrhage and Migraine are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.
Subarachnoid Hemorrhage vs Migraine at a glance
- Subarachnoid Hemorrhage: Bleeding into the subarachnoid space, usually from a ruptured saccular aneurysm.
- Migraine: Recurrent primary headache disorder with unilateral throbbing pain, photophobia, nausea.
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Side-by-side comparison
| Feature | Subarachnoid Hemorrhage | Migraine |
|---|---|---|
| At a glance | Bleeding into the subarachnoid space, usually from a ruptured saccular aneurysm. | Recurrent primary headache disorder with unilateral throbbing pain, photophobia, nausea. |
| Classic presentation | Thunderclap headache + meningismus + LOC. Hunt-Hess and World Federation of Neurosurgical Societies (WFNS) grading scales predict outcome.; Sudden severe headache ('thunderclap,' 'worst headache of life,' maximal within seconds); Brief loss of consciousness in ~50%; Nausea, vomiting, photophobia; Meningismus develops over hours from… | POUND mnemonic: Pulsatile, One-day duration (4-72 h), Unilateral, Nausea, Disabling — 4 of 5 features highly suggest migraine.; Prodrome (hours-days before): mood changes, food cravings, neck stiffness, yawning, urinary frequency; Aura (~25%): visual (scintillating scotoma, fortification spectra, hemianopia), sensory (paresthesias… |
| Workup / key labs | Subarachnoid blood on CT in basal cisterns, sylvian fissure, or interhemispheric fissure; or xanthochromia on LP.; CBC, coagulation panel, BMP, troponin (neurogenic stunned myocardium common); Type and screen | ICHD-3 criteria: ≥5 attacks lasting 4-72 hours, with ≥2 of [unilateral, pulsating, moderate-severe, aggravated by activity] AND ≥1 of [nausea/vomiting, photophobia + phonophobia].; Generally not indicated for typical migraine; ESR/CRP if temporal arteritis suspected (age >50); CBC, BMP if atypical features |
| Imaging | Non-contrast head CT within 6 h of symptom onset is ~100% sensitive (drops to ~85% at 24 h, ~50% at 1 week); Lumbar puncture if CT negative but clinical suspicion remains — xanthochromia (yellow CSF from hemoglobin breakdown) confirms SAH; RBCs that don't clear between tubes 1 and 4; CT angiography head/neck — identifies aneurysm… | Neuroimaging NOT routinely indicated for typical migraine with normal exam; MRI brain indicated for: red flags (SNOOP: Systemic symptoms/Secondary risk factors, Neurologic signs, Onset sudden/thunderclap, Older age >50 with new headache, Pattern change/Progressive/Positional/Precipitated by Valsalva); Lumbar puncture if SAH or… |
| First-line treatment | ABCs; intubate if GCS ≤8 or airway compromise; BP control: target SBP <160 (or MAP <110) until aneurysm secured — IV nicardipine, clevidipine, or labetalol; Pain control (acetaminophen, opioids; avoid antiplatelet/NSAID); Antiemetics, stool softeners (avoid Valsalva); Nimodipine 60 mg PO/NG q4h × 21 days — improves neurologic outcomes… | Abortive: NSAIDs (ibuprofen 400-800 mg, naproxen 500 mg) for mild-moderate attacks; Triptan — sumatriptan 50-100 mg PO (also 6 mg SC, 20 mg nasal), rizatriptan 10 mg, eletriptan 40 mg — best taken at headache onset; contraindicated with CAD, uncontrolled HTN, prior stroke, hemiplegic/basilar migraine, ergot use within 24 h; Combination… |
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