6.3.1 Headache attributed to unruptured saccular aneurysm

A 45-year-old female patient, a teacher, presents to the emergency department complaining of severe and persistent headache for 5 days.

History of Present Illness:
The patient reports a sudden onset of holocranial headache, described as "the worst pain of her life," with an intensity of 9/10, associated with photophobia and nausea, but without vomiting. She denies recent head trauma, fever, or infections. She notes that the pain does not improve with common analgesics (paracetamol and dipyrone). She also reports that over the past 2 months, she has experienced recurrent episodes of mild to moderate headache, which she attributed to work-related stress.

Past Medical History:
Systemic arterial hypertension controlled with losartan. Denies smoking, alcohol use, or illicit drug use. No previous history of chronic headaches or migraines.

Physical Examination:

General: conscious, oriented, hydrated, in fair general condition.

Neurological: pupils are isocoric and reactive to light, without motor or sensory deficits. Normal reflexes. Negative meningitis sign (absence of neck stiffness).

Other systems: no relevant alterations.

Complementary Exams:

Non-contrast cranial computed tomography (CT): no signs of subarachnoid hemorrhage or expansive lesions.

Magnetic resonance angiography (MRA): identified a 7 mm saccular aneurysm in the right middle cerebral artery, without signs of rupture.

Lumbar puncture: clear cerebrospinal fluid (CSF), with normal opening pressure, no red blood cells or xanthochromia.