If a patient reports "the worst headache of my life," which condition should be primarily considered?

When a patient reports experiencing "the worst headache of my life," the primary concern should be for a subarachnoid hemorrhage. This type of headache is often characterized as sudden and severe, and it typically arises from bleeding in the space surrounding the brain, often due to the rupture of an aneurysm or a vascular malformation.

The intensity of the headache, combined with a sudden onset, is a hallmark feature of subarachnoid hemorrhage, setting it apart from other headache types. In many cases, this headache may be accompanied by other alarming symptoms, such as neck stiffness, altered mental status, or focal neurological deficits, which necessitate immediate medical evaluation and intervention.

In contrast, chronic tension headaches, cluster headaches, and sinus headaches usually present differently or with less severity. Chronic tension headaches tend to be more of a dull, aching sensation rather than a severe, acute pain. Cluster headaches can be extremely painful but are usually experienced in cyclical patterns or clusters, typically localized to one side of the head, and often coincide with autonomic symptoms like lacrimation. Sinus headaches often manifest with sinus congestion and may respond to decongestants, whereas a subarachnoid hemorrhage requires urgent neurological assessment and treatment.