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The headache starts very suddenly, without any warning at all, and feels as if you’ve been hit hard on the back of the head or neck or, alternatively, that there’s been an explosion inside the head. The pain is extreme.

What else could it be?

Four conditions can mimic or be mimicked by a sub-arachnoid haemorrhage:

Meningitis gives the same type of stiff neck, in which the patient is unable to bend his chin to his chest (remember that a true stiff neck is one that cannot be bent forwards). Like a sub-arachnoid haemorrhage, meningitis can also come on quite quickly (but in a matter of hours, not minutes) and soon produces altered consciousness, irritability and drowsiness. Hut patients with meningitis almost always have a temperature, even if it’s only a small one,.

In practice, for the lay person the difference is unimportant. In both cases you need a doctor and you need one now. Don’t wait for the morning; don’t wait even five minutes – it could be the difference between life and death.

A stroke can cause sudden headache, collapse and unconsciousness, within a few minutes. However, paralysis is usually one-sided, with one arm or leg obviously more floppy and paralysed than on the other side.

Headaches coming on during intercourse can mimic a sub-arachnoid haemorrhage, because they come on very quickly, and sometimes almost explosively; and, of course, a sub-arachnoid haemorrhage can be precipitated by the excitement and stress of intercourse. In fact, if a headache of this type and magnitude occurs during intercourse, it may be wise to do a full medical investigation, just to be sure. Once a sub-arachnoid haemorrhage has been eliminated, then it is fair to assume that any further headaches during intercourse are not likely to be sub-arachnoid bleeds.

A very severe tension headache can actually be quite difficult to distinguish from a sub-arachnoid haemorrhage, particularly if it has a sudden onset – such as a sudden tensing of the muscles as a result of a fright; or in a minor injury to the head which reflexively results in all the neck muscles going into spasm (for example, bringing your head up underneath a cupboard, hitting it hard and finding that the resultant reflex pulling of the head downwards by the neck muscles has sent all of them into spasm).

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Typically, the pain is in the front of the face, around one or both eyes, though as there are four different sets of sinuses, the site of pain coming from each is slightly different. Pressure ewer the affected sinus causes an instant increase in pain; and the pain also worsens when the head is bent down towards the knees (because the pressure of the blood pooling in the veins adds to the pressure inside the sinuses). Anything that increases the pressure or the amount of fluid in the sinuses will increase the pain, so often sinus pain is worse on lying down. You may wake with a headache, which will go after being upright for a time as the blood-vessel congestion reduces slightly. However, pain from the frontal sinus can sometimes start an hour or two after getting up, and then get better in the afternoon.

What else could it be?

Pain centred around an eye could be migraine (but in migraine there are usually changes in the vision, together with vomiting). The pain of glaucoma settles round one eye, but the eye is usually inflamed and the vision will be blurred; pain radiating from the back of the neck in a tension headache or in cervical spondylosis can be sensed in one eye, but there won’t be a raised temperature, and the pain won’t increase much if you bend or lie down.

Toothache and sinus pain can often be very difficult to tell apart, particularly as some of the upper front teeth, especially the upper canines (the ‘eye teeth’, slightly pointed ones just to the side of the front of the mouth) have their roots embedded in the bottom wall of the bone that forms one of the sinuses. A root abscess in a tooth here (that’s an abscess at the very end of the root of the tooth) can be excruciatingly painful and, just like sinusitis, can also give more pain if you put your head down. However, the offending tooth is often very tender when touched or banged, and the pain doesn’t normally increase when pressure is put on the hone overlying the sinuses (though pressure on the bone under the gum certainly Increases the pain).

In addition, a nasal-sounding voice, a history of nasal allergies, or pus dripping down the nose are usually pretty obvious indicators that the pain is sinus rather than dental. However, in difficult cases you may need to see both doctor and dentist – sinus and dental X-rays may be necessary before the diagnosis can be made with certainty.

Just occasionally sinus pain which doesn’t go away with treatment can indicate a 11 nicer of the sinuses, so if your pain doesn’t get better, be sure to check with your doctor – though in most cases, it will be simply because the bacteria responsible for the infection are resistant to the antibiotics that are being used.

finally, high blood pressure can give the same pattern of headaches – worse on rising – but there won’t be facial tenderness, and, obviously, your blood pressure will be high.

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Migraine in childhood behaves slightly differently from migraine in adults. As we have already seen it can sometimes occur as stomach pain – abdominal migraine.

However, many children get common or classical head migraines, sometimes alternating between the abdominal and head pain; and others get abdominal pain at the time that the aura would occur in an adult.

Even in children with normal migraine, there are differences between childhood and adult attacks. In children, attacks tend to be frequent and severe, though normally slightly shorter than in adults, and there can be long periods in between the bouts. Incomplete attacks are common. There may be many more generalised symptoms – nausea, vomiting, sweating, passing water frequently, or water retention.

In children there is an association between migraine and travel sickness and with dizziness. It is possible also that repeated attacks of unexplained vomiting (the so-called ‘periodic’ syndrome) actually are a form of migraine. It may develop into full migraine in later life.

Before puberty, migraine occurs more often in males, which is the reverse of the over-all picture, but after puberty the oestrogen levels of young girls rise. It is oestrogen which is the factor responsible for the preponderance of migraine in women. Basilar migraine is most common in adolescent girls, and ophthalmoplegic migraine in young boys.

The relationship between childhood and adult migraine isn’t certain; some lose their attacks only to get them back later. However, of those who have migraine in childhood, approximately half will have slopped having attacks by the age of thirty.

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