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      <h1 class="highwire-cite-title" id="page-title">Sentinel Headache: A Warning Sign Preceding Every Fourth Aneurysmal Subarachnoid Hemorrhage</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">H. Joswig</span>, <span class="highwire-citation-author" data-delta="1">J.Y. Fournier</span>, <span class="highwire-citation-author" data-delta="2">G. Hildebrandt</span> and <span class="highwire-citation-author" data-delta="3">M.N. Stienen</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">September 2015,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">36 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(9) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E62-E63; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A4467 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-14158--61006924904" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">H. Joswig </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Neurosurgery
Cantonal Hospital St. Gallen
St. Gallen, Switzerland</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=H.%2BJoswig%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Joswig%20H&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AH.%2BJoswig%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">J.Y. Fournier </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Neurosurgery
Cantonal Hospital St. Gallen
St. Gallen, Switzerland</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=J.Y.%2BFournier%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Fournier%20J&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AJ.Y.%2BFournier%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">G. Hildebrandt </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Neurosurgery
Cantonal Hospital St. Gallen
St. Gallen, Switzerland</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=G.%2BHildebrandt%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Hildebrandt%20G&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AG.%2BHildebrandt%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-3"><div class="author-tooltip-name">M.N. Stienen </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Neurosurgery
Cantonal Hospital St. Gallen
St. Gallen, Switzerland</div><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Neurosurgery
Hôpitaux Universitaires de Genève
Geneva, Switzerland</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=M.N.%2BStienen%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Stienen%20M&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AM.N.%2BStienen%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">With great interest, we read the recent retrospective study of Oda et al<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> in the <em>American Journal of Neuroradiology</em> reporting a 33.9% incidence of minor leaks preceding aneurysmal subarachnoid hemorrhage (aSAH) confirmed by neuroradiologic methods, in which the authors found a much lower incidence of sentinel headache (SH) of 11% by patient interview. Our data from an ongoing Swiss prospective observational study (ClinicalTrials.gov identifier: <a class="external-ref external-ref-type-clintrialgov" href="/lookup/external-ref?link_type=CLINTRIALGOV&amp;access_num=NCT02129010&amp;atom=%2Fajnr%2F36%2F9%2FE62.atom">NCT02129010</a>) confirms that SH preceding aSAH is not by any means a rare phenomenon. In 8 (24.2%) of 33 patients, SH was confirmed by either the patient or next of kin. Contrary to those of Oda et al,<sup><a id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1</a></sup> the data from our study (<a id="xref-table-wrap-1-1" class="xref-table" href="#T1">Table</a>) do not indicate any difference in radiologic bleeding characteristics, such as the presence of intracerebral hemorrhage and a higher rebleeding rate, or worse outcome in patients with SH. Nonetheless, mortality in our SH group was considerably high (37.5%), which once again renders distinguishing dangerous headache from innocuous headache on clinical grounds of paramount importance. In the absence of nuchal rigidity, a diminished level of consciousness, or focal neurologic deficits, any sudden onset of atypical headache should raise the suspicion of SH and should be followed by further investigations. It is therefore important to appreciate the sensitivity and specificity and the limitations of CT and lumbar puncture.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup></p><div id="T1" class="table pos-float"><div class="table-inline table-callout-links"><div class="callout"><span>View this table:</span><ul class="callout-links"><li class="view-inline first"><a href="" class="table-expand-inline" data-table-url="/highwire/markup/44759/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed&amp;table-expand-inline=1" data-icon-position="" data-hide-link-title="0">View inline</a></li><li class="view-popup last"><a href="/highwire/markup/44759/expansion?width=1000&amp;height=500&amp;iframe=true&amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed" class="colorbox colorbox-load table-expand-popup" rel="gallery-fragment-tables" data-icon-position="" data-hide-link-title="0">View popup</a></li></ul></div></div><div class="table-caption"><p id="p-2" class="first-child">Characteristics of patients with aneurysmal subarachnoid hemorrhage with and without sentinel headache<sup><sup>a</sup></sup></p><div class="sb-div caption-clear"></div></div></div><p id="p-8">Education on a primary care level is key to correctly identifying SH and preventing major aSAH with its subsequent morbidity and mortality. For example, a Swedish educational program for local physicians proved to be effective in reducing diagnostic errors by 77%.<sup><a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a></sup> Whether any of our 8 patients confirmed positive for SH previously sought medical attention was not explicitly investigated by the study protocol. To consolidate awareness among primary care physicians, this short report of prospectively collected data complementing the retrospective study of Oda et al<sup><a id="xref-ref-1-3" class="xref-bibr" href="#ref-1">1</a></sup> is meant to highlight the importance of SH preceding aSAH: About every fourth patient with aSAH has preceding symptoms.</p><div class="section ack" id="ack-1"><h2 class="">Acknowledgments</h2><p id="p-9">CSF protein INNOTEST ELISA test kits were provided by Innogenetics N.V. (Ghent, Belgium); this funding source has no role in the acquisition of the data stated in the current report.</p><p id="p-10">The current study was approved by the ethics committee, St. Gallen, Switzerland (EKSG 13/011/1B). All study participants or substitute decision makers gave informed consent before taking part. Study protocol can be found at ClinicalTrials.gov (Identifier: <a class="external-ref external-ref-type-clintrialgov" href="/lookup/external-ref?link_type=CLINTRIALGOV&amp;access_num=NCT02129010&amp;atom=%2Fajnr%2F36%2F9%2FE62.atom">NCT02129010</a>).</p></div><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-36.9.E62.1" data-doi="10.3174/ajnr.A4325"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Oda</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Shimoda</span>  <span class="cit-name-given-names">M</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Hirayama</span>  <span class="cit-name-given-names">A</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Neuroradiologic diagnosis of minor leak prior to major SAH: diagnosis by T1-FLAIR mismatch</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2015</span> 
<span class="cit-month">May</span> 
<span class="cit-day">14</span>. <span class="cit-comment">[Epub ahead of print]</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.3174/ajnr.A4325</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>25977479</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo5OiIzNi85LzE2MTYiO3M6NDoiYXRvbSI7czoxOToiL2FqbnIvMzYvOS9FNjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-36.9.E62.2" data-doi="10.1056/NEJM200001063420106"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Edlow</span>  <span class="cit-name-given-names">JA</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Caplan</span>  <span class="cit-name-given-names">LR</span></span></li></ol><cite>. <span class="cit-article-title">Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage</span>. <abbr class="cit-jnl-abbrev">N Engl J Med</abbr> <span class="cit-pub-date">2000</span>;<span class="cit-vol">342</span>:<span class="cit-fpage">29</span>–<span class="cit-lpage">36</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1056/NEJM200001063420106</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>10620647</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1056/NEJM200001063420106&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=10620647&amp;link_type=MED&amp;atom=%2Fajnr%2F36%2F9%2FE62.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a><div class="cit ref-cit ref-journal" id="cit-36.9.E62.3" data-doi="10.1034/j.1600-0404.2001.103004238.x"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Fridriksson</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Hillman</span>  <span class="cit-name-given-names">J</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Landtblom</span>  <span class="cit-name-given-names">AM</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Education of referring doctors about sudden onset headache in subarachnoid hemorrhage: a prospective study</span>. <abbr class="cit-jnl-abbrev">Acta Neurol Scand</abbr> <span class="cit-pub-date">2001</span>;<span class="cit-vol">103</span>:<span class="cit-fpage">238</span>–<span class="cit-lpage">42</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1034/j.1600-0404.2001.d01-27.x</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>11328195</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1034/j.1600-0404.2001.103004238.x&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=11328195&amp;link_type=MED&amp;atom=%2Fajnr%2F36%2F9%2FE62.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2015 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 36</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 9 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Sep 2015 </div></div>
      
      
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      <div class="highwire-cite-title">Sentinel Headache: A Warning Sign Preceding Every Fourth Aneurysmal Subarachnoid Hemorrhage</div>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">H.</span> <span class="nlm-surname">Joswig</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">J.Y.</span> <span class="nlm-surname">Fournier</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">G.</span> <span class="nlm-surname">Hildebrandt</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">M.N.</span> <span class="nlm-surname">Stienen</span></span></span></div>
  
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      <div class="highwire-cite-title">Sentinel Headache: A Warning Sign Preceding Every Fourth Aneurysmal Subarachnoid Hemorrhage</div>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">H.</span> <span class="nlm-surname">Joswig</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">J.Y.</span> <span class="nlm-surname">Fournier</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">G.</span> <span class="nlm-surname">Hildebrandt</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">M.N.</span> <span class="nlm-surname">Stienen</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Sep 2015, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">36 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(9) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E62-E63; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A4467 </span></div>
  
  
  
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