Background Aneurysmal subarachnoid hemorrhage (SAH) is the most common cause of nontraumatic SAH. Current guidelines generally recommend observation for unruptured intracranial aneurysms smaller than 7 mm, for those are considered at low risk for spontaneous rupture according to available scoring systems. Objective We observed a tendency for SAH in small intracranial aneurysms in patients who are methamphetamine users. A retrospective, single center study to characterize the size and location of ruptured and unruptured intracranial aneurysms in methamphetamine users was performed. Materials and methods Clinical characteristics and patient data were collected via retrospective chart review of patients with intracranial aneurysms and a history of methamphetamine use with a specific focus on aneurysm size and location. Results A total of 62 patients were identified with at least one intracranial aneurysm and a history of methamphetamine use, yielding 73 intracranial aneurysms (n = 73). The mean largest diameter of unruptured aneurysms (n = 44) was 5.1 mm (median 4.5, SD 2.5 mm), smaller than for ruptured aneurysms (n = 29) with a mean diameter of 6.3 mm (median 5.5, SD 2.5 mm). Aneurysms measuring less than 7 mm presented with SAH in 36.5%. With regard to location, 28% (n = 42) of anterior circulation aneurysms less than 7 mm presented with rupture, in contrast to 70% (n = 10) of posterior circulation aneurysms which were found to be ruptured. Conclusions Methamphetamine use may be considered a significant risk factor for aneurysmal SAH at a smaller aneurysm size than for other patients. These patients may benefit from a lower threshold for intervention and/or aggressive imaging and clinical follow-up.