13-009 · EVIDENCE A · SOURCE-SENSITIVE
A sudden “worst headache of one’s life” that peaks within an hour — go to the ER for a head CT right away
突然一记「这辈子最疼的头痛」，一小时内就到最疼，立刻去急诊做头颅 CT
An emergency visit itself costs very little. A head CT in the ER typically runs a few hundred yuan.
The key point isn’t how intense the pain is, but how quickly it reaches its peak. In 2,131 people experiencing severe headaches that peaked within an hour, 6.2% had a ruptured blood vessel on the surface of the brain. Anyone aged 40 or older, with neck pain or stiffness, who was seen collapsing by others, whose headache started during physical activity, came on suddenly like an explosion, or has limited neck flexion when examined should go to the ER for a head CT. The vast majority of people who get tested end up fine, but missing even one case of bleeding can be fatal.
A
Move “A sudden “worst headache of one’s life” that peaks within an hour — go to the ER for a head CT right away” to Future Me's calendar
The excuse
Future Me has a clearer calendar, more patience, and apparently the same responsibilities.
What feels good now
Today I keep a little money, a few minutes and avoid interrupting my default routine.
What the source says
The source summarizes the return this way: “The key point isn’t how intense the pain is, but how quickly it reaches its peak. In 2,131 people experiencing severe headaches that peaked within an hour, 6.2% had a ruptured blood vessel on the surface of the brain. Anyone aged 40 or older, with neck pain or stiffness, who was seen collapsing by others, whose headache started during physical activity, came on suddenly like an explosion, or has limited neck flexion when examined should go to the ER for a head CT. The vast majority of people who get tested end up fine, but missing even one case of bleeding can be fatal.” Evidence grade A. The original states the population, caveats, and sources; this is not a personal forecast.
Use the original facts and limits. For an urgent medical, safety, financial, or legal issue, contact a qualified local professional or service.
THE ENGLISH EDITION
Original recommendation and evidence
9. A sudden “worst headache of one’s life” that peaks within an hour — go to the ER for a head CT right away
Cost: An emergency visit itself costs very little. A head CT in the ER typically runs a few hundred yuan.
In plain terms: The key point isn’t how intense the pain is, but how quickly it reaches its peak. In 2,131 people experiencing severe headaches that peaked within an hour, 6.2% had a ruptured blood vessel on the surface of the brain. Anyone aged 40 or older, with neck pain or stiffness, who was seen collapsing by others, whose headache started during physical activity, came on suddenly like an explosion, or has limited neck flexion when examined should go to the ER for a head CT. The vast majority of people who get tested end up fine, but missing even one case of bleeding can be fatal.
Benefit: Ten Canadian emergency departments conducted a prospective cohort study on 2,131 patients with “severe headaches peaking within an hour.” They defined clear criteria upfront and tracked outcomes accordingly. Of these, 132 patients (6.2%) had subarachnoid hemorrhage, meaning a ruptured surface blood vessel in the brain. The Ottawa SAH rule includes six criteria: age 40 or older, neck pain or stiffness, witnessed loss of consciousness, onset during physical activity, sudden explosive onset of pain, and limited neck flexion on physical exam. Meeting any one of these criteria triggers a CT scan. This rule identified every single patient with bleeding, with 100% sensitivity. The 95% confidence interval for this figure is 97.2%–100.0%. The trade-off is that only 15.3% of people without bleeding were excluded by this rule (specificity of 15.3%).
Evidence grade: A
Sources: Perry JJ, Stiell IG, Sivilotti MLA, et al. (2013). Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA, 310(12), 1248-1255. <https://doi.org/10.1001/jama.2013.278018>
Notes: It’s not “how painful it is” that matters, but “how fast it reaches peak pain.” Headaches that erupt within seconds to a minute are the real warning sign; gradually worsening migraines are not. Additional symptoms like vomiting, neck stiffness, light sensitivity, or brief fainting also warrant immediate attention. With a specificity of just 15.3%, most people who follow this rule end up with normal results. Yet missing even one case of bleeding can be fatal, so getting tested is absolutely worthwhile. Do not take painkillers to mask the pain and then fall asleep.
Read the complete Chinese source and notes
9. 突然一记「这辈子最疼的头痛」，一小时内就到最疼，立刻去急诊做头颅 CT
成本: 看急诊本身不花什么钱。急诊做一次头颅 CT 几百元。
说人话: 要看的是多快疼到最厉害。一小时内疼到顶的剧烈头痛，约 6% 是脑表面的血管破了。40 岁以上、脖子痛或发硬、有人看到你晕过去、活动中起病、瞬间炸开、脖子往前低不下去，中一条就去急诊做头颅 CT。去查的人大多没事，但漏一次再出血就是死亡。
收益: 加拿大 10 家急诊对 2131 例「一小时内达到最痛的剧烈头痛」做了前瞻队列研究，事先定好标准，再一路跟踪记录。其中 132 例（6.2%）是蛛网膜下腔出血（脑表面的血管破了）。渥太华 SAH 规则有六条：40 岁及以上、脖子痛或者发硬、有人看到晕过去。另外三条是活动中发作、一下子炸开式发作、医生查体时脖子前屈受限。符合任一条就要查。这条规则把出血的人全都挑了出来，敏感性 100%，95% CI 97.2%–100.0%（可信范围）。代价是没出血的人里只有 15.3% 被它排除掉（特异性 15.3%）
证据等级: A
来源: Perry JJ, Stiell IG, Sivilotti MLA, et al. (2013). Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA, 310(12), 1248-1255. <https://doi.org/10.1001/jama.2013.278018>
备注: 要看的不是「有多疼」，是「多快到最疼」，几秒到一分钟内炸开的头痛才是危险信号，慢慢加重的偏头痛不是。伴呕吐、脖子发硬、怕光、短暂晕厥，更要当回事。特异性只有 15.3%，意思是按这条去查的人绝大多数查完没事。但漏掉一次再出血就是死亡，值得查。不要吃片止痛药压下去接着睡
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