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Department of Neurology, University of Münster, Albert-Schweitzer Strasse 33, 48129 Münster, Germany; fresea@uni-muenster.de

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Dr Larner highlights an important diagnostic problem. The sensitivity of brain CT to subarachnoid haemorrhage (SAH) is high (95%) within the first 48 hours after onset but drops to 30% after two weeks. CSF analysis can show xanthocromia for up to four weeks but its sensitivity also decreases after two weeks. There is no evidence on how to manage patients with a single orgasmic headache presenting later than 2–4 weeks after onset. From our personal experience, we would suggest CT or MR angiography to exclude an intracranial aneurysm. Both techniques have a sensitivity >85% to detect aneurysms larger than 2 mm diameter. Digital subtraction catheter angiography is still the gold standard to exclude very small aneurysms but is invasive, relatively expensive, and carries the risk of neurological complications;¹ it should therefore be reserved for when there are atypical manifestations of orgasmic headache presenting with "red flags" indicative of symptomatic headaches . . . [Full text of this article]