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A 40-year-old man with hypertension comes to the emergency department complaining of a severe headache that started the previous evening while exercising at the gym. He states that the headache came on suddenly and describes a constant throbbing pain on the top of his head and down the back of his neck. He did not experience any loss of consciousness, but does complain of nausea and says that he vomited twice last night. He also complains of blurry vision, dizziness, and fatigue. He experienced a similar, but less severe headache one week ago that resolved spontaneously after about 2 hours. He has tried ibuprofen and some acetaminophen with codeine that he had left over from a previous tooth extraction, but has not had any relief of his symptoms. He waited to come to the hospital this morning because he thought the headache was due to the stress he has been experiencing at work and that it would resolve on its own. He smokes 1 pack of cigarettes per day, drinks alcohol occasionally, and does not do any illicit drugs. His temperature is 37.0 C (98.6 F), blood pressure is 158/90 mm Hg, pulse is 62/min, respirations are 18/min, and oxygen saturation is 99%. Physical examination shows a well-developed man lying on the stretcher with his right hand covering his eyes in obvious distress secondary to pain. His pupils are equal, round, and reactive to light and accommodation however, you are unable to examine of the fundi due to the patient's discomfort with the light. Cranial nerves II-XII are intact. He has some neck stiffness with flexion and extension. The remainder of the physical and neurologic examination shows difficulty with bilateral finger to nose precision as well as heel to shin coordination. You order a non-contrast CT scan of his head, which is read as normal. The most appropriate next step in the management of this patient is to

A. administer intravenous analgesia with morphine and metoclopramide and observe in the emergency department

B. administer subcutaneous sumatriptan and discharge home to follow up with a neurologist

C. obtain an urgent neurosurgical consultation and a cerebral angiogram

D. perform a lumbar puncture with CSF analysis


E. request psychiatric evaluation for acute stress reaction

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