A 50-year-old man suddenly developed excruciating neck and occipital pain in his car while stationary at a set of traffic lights. He described it “as though (he) had been hit over the back of the head”. Associated with this he described a “rushing” sensation extending into his head, “numbness and tingling” in his lower jaw, a “tightness” in his throat and, on direct questioning, pulsatile tinnitus in his left ear. He felt nauseated, light headed and was sweating profusely. He had previously been well, without any significant past medical problems, vascular risk factors or history of cervical manipulation. He went to his general practitioner who referred him urgently to the neurologist on call for consideration of subarachnoid haemorrhage (SAH).

On admission, he looked unwell and was clammy and restless. Vital signs were unremarkable. His pupils were miotic but equal, without associated ptosis, and were reactive to light. He had not received opiates or taken any recreational drugs. He was intolerant of fundoscopy suggesting photophobia although he did not admit to this on direct questioning. There was ill defined tenderness over the cervical musculature but no meningism. There were no focal neurological signs.

His admission ECG and brain CT were both normal. He was kept on bed rest under close observation and given intravenous fluids, analgesia and antiemetics.