Presumed migraine

A 49-year-old woman presents to the Emergency Department with a presumed migraine. She developed a sudden, severe thunderclap headache approximately 90 minutes earlier, associated with vomiting, photophobia and neck stiffness. The triage nurse is concerned about her confusion and severe pain and transfers her to Resus for urgent senior assessment. You are the Emergency Medicine registrar.

Initial observations

Heart rate 92 bpm, sinus rhythm. Blood pressure 178/98 mmHg. Respiratory rate 18/min. SpO₂ 98% on room air. Temperature 36.9°C. GCS 14 — E4 V4 M6. Blood glucose 6.0 mmol/L. Pupils equal and reactive.

ABCDE

A — Airway: Patent.
B — Breathing: Spontaneously breathing, equal air entry, no significant respiratory compromise.
C — Circulation: Hypertensive, sinus rhythm, adequately perfused.
D — Disability: GCS 14, confusion, severe headache, photophobia and neck stiffness. No focal limb weakness. Pupils equal and reactive.
E — Exposure: No trauma, rash or fever identified.

The monitor stays off until she is in Resus.