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Sentinel Headache and the Rate of Rebleeding After Subarachnoid Hemorrhage

Three Part Question

Do [adult patients with a sentinel headache] have a [higher rate of rebleeding] after [subarachnoid hemorrhage]?

Clinical Scenario

A 60 year hold woman presents to the ED with a headache. She has a history of migraines, but thinks this one may be slightly worse than in the past. She has no associated neurological changes. She is treated symptomatically and discharged home. One week later she presents back to the ED with altered mental status and is found to have a subarachnoid hemorrhage (SAH). Do patients having a sentinel headache (or warning leak) before an aneurysmal SAH have a worse clinical outcome?

Search Strategy

Medline 1950-07/08 using OVID interface, Cochrane Library (2008), PubMed clinical queries
[(exp Subarachnoid hemorrhage or subarachnoid AND (warning or]. LIMIT to human AND English

Search Outcome

28 papers were found of which 3 were relevant to the three part question

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Jakobsson, KE et al
December 1996
422 patients with aneurysmal SAH admitted to neurological center in Sweden over a 4 year periodProspective observational trialMean systolic blood pressure (mmHg) at baseline and 2hrs 125+/- 19 and 119 +/-15 (ranitidine gp) vs 132+/-19 and 112 +/- 18 (placebo gp). No difference.
Absence of angioedema and urticaria at 2h70.5% (ranitidine gp) vs 46.5% (placebo gp). 72 patients total, P= 0.02


Some patients with SAH report unusual, severe headaches in the weeks preceding their SAH diagnosis–a phenomenon loosely described in the literature "sentinel headache." The reported incidence of a sentinel headache in SAH patients ranges from 13.5% to 60%. The true incidence of a warning leak in patients with SAH is difficult to establish because of the inability to obtain complete information on those patients in poor clinical condition and those who die before reaching a hospital. While several causes have been proposed for sentinel headaches, it is likely that it represents minor bleeding from the aneurysm, which would account for the adverse effect on clinical outcome.

Clinical Bottom Line

Sentinel headache may increase the risk of rebleeding in SAH; the ability to recognize and aggressively treat those patients with sentinel headache may improve patient outcomes


  1. Jakobsson, KE Warning leak and management outcome in aneurysmal subarachnoid hemorrhage Journal of Neurosurgery December 1996;85:995-999
  2. Ritz, R and Reif, J Comparison of prognosis and complications after warning leaks in subarachnoid hemorrhage - experience with 214 patients following aneurysm clipping Neurological Research September 2005;27; 620-624