Regarding approach to a a patient presenting with worst headache of life

A 27-year-old presents with the worst headache of his life. Which of the following is least likely to be helpful?

A. Careful history eliciting recent trauma or head injury
B. Evaluation of cranial nerves including the retina
C. Strong consideration of CT or MRI of the head
D. Plain film of the skull
E. History of previous headache problems and treatments

Answer : D. Plain film of the skull

Discussion: Patients with the “worst headache of their life” must be considered to have a potentially catastrophic process such as a ruptured or leaking aneurism or intracranial bleed. A thorough history of past headaches (e.g., migraine), recent trauma or head injury, and associated symptoms such as fever is important. The physician should perform a careful neurologic examination. The physician should strongly consider a CT or MRI of the head in such situations. 

A plain film of the skull will provide little useful information and is insensitive to the conditions of most concern. 

Imaging prior to a lumbar puncture is usually performed to rule out a mass lesion that could predispose to brain herniation. A negative CT scan will not rule out a subarachnoid bleed, particularly a small (sentinel) bleed days later in the course.