The anchoring trap
Because the patient had previous headaches, both patient and family initially treated the episode with usual analgesics.
The red flag
This pain reached maximum intensity almost instantly and was accompanied by vomiting and neck discomfort. It was unlike the gradual pattern of previous attacks.
The twist
Emergency neuroimaging identified an acute intracranial haemorrhagic process.
Take-home message
A previous migraine diagnosis should not explain every future headache. Sudden thunderclap onset, neurological deficits, altered consciousness or a major pattern change requires urgent assessment.
Diagnostic principle: do not let the first plausible label stop the search when an important detail does not fit.
Educational note: This is a teaching composite, not a substitute for patient-specific diagnosis or treatment. Real patients require direct clinical assessment and appropriate investigations.