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ABSTRACT: Headache is one of the most common reasons for presentation to the emergency department (ED), seen in up to 2% of patients. Most are benign, but it is imperative to understand and discern the life-threatening causes of headache when they present. Headache caused by a subarachnoid hemorrhage (SAH) from a ruptured aneurysm is one of the most deadly, with a median case-fatality of 27-44%. Fortunately, it is also rare, comprising only 1% of all headaches presenting to the ED. On initial presentation, the one-year mortality of untreated SAH is up to 65%. With appropriate diagnosis and treatment, mortality can be reduced to 18%. The implications are profound: Our careful assessment  leading to the detection of a SAH as the cause of headache can significantly decrease our patients’ mortality. If this were an easy task, the 12% reported rate of missed diagnosis would not exist. We have multiple tools and strategies to evaluate the patient with severe headache and must understand the strengths and limitations of each tool. Herein we will describe the available strategies, as well as the ED management of the patient with SAH. [West J Emerg Med. 2019;20(2)203-211.]

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