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Thunderclap headache: An approach to a neurologic emergency

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Abstract

Thunderclap headache (TCH) refers to an excruciating headache of instantaneous onset. Recognition and accurate diagnosis of this headache are important because it can be caused by various serious underlying brain disorders such as subarachnoid hemorrhage, intracranial hematoma, cerebral venous sinus thrombosis, cervical artery dissection, ischemic stroke, pituitary apoplexy, acute arterial hypertension, spontaneous intracranial hypotension, third ventricle colloid cyst, and intracranial infections. Patients with TCH who have evidence of reversible, segmental, cerebral vasoconstriction of circle of Willis arteries and normal or near-normal cerebrospinal fluid evaluation are considered to have reversible cerebral vasoconstriction syndrome. Primary TCH is diagnosed when no underlying etiology is identified. In this review, we discuss the differential diagnosis of ICH, outline the characteristics and diagnostic criteria for primary TCH, offer a pathophysiologic hypothesis for primary TCH, and detail the diagnostic evaluation of the patient presenting with TCH.

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References and Recommended Reading

  1. Day JW, Raskin NH: Thunderclap headache: symptom of unruptured cerebral aneurysm. Lancet 1986, 2:1247–1248.

    PubMed  CAS  Google Scholar 

  2. Schwedt TJ, Matharu MS, Dodick DW: Thunderclap headache. Lancet Neurol 2006, 5:621–631.

    Article  PubMed  Google Scholar 

  3. Linn FH, Wijdicks EF: Causes and management of thunderclap headache: a comprehensive review. Neurologist 2002, 8:279–289.

    Article  PubMed  CAS  Google Scholar 

  4. Landtblom AM, Fridriksson S, Boivie J, et al.: Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia 2002, 22:354–360.

    Article  PubMed  Google Scholar 

  5. Linn FH, Wijdicks EF, van der Graaf Y, et al.: Prospective study of sentinel headache in aneurysmal subarachnoid hemorrhage. Lancet 1994, 344:590–593.

    Article  PubMed  CAS  Google Scholar 

  6. Ferro JM, Lopes J, Melo TP: Investigation into the causes of delayed diagnosis of subarachnoid hemorrhage. Cerebrovasc Dis 1991, 1:160–164.

    Article  Google Scholar 

  7. Linn FH, Rinkel GJ, Algra A, van Gijn J: Headache characteristics in subarachnoid hemorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 1998, 65:791–793.

    Article  PubMed  CAS  Google Scholar 

  8. Sandercock PA, Hankey GJ, van Gijn J, et al.: Stroke: A Practical Guide to Management, edn 2. Oxford: Blackwell Science; 2000.

    Google Scholar 

  9. Pascual J, Iglesias F, Oterino A, et al.: Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 1996, 46:1520–1524.

    PubMed  CAS  Google Scholar 

  10. van Gijn J, Rinkel GJ: Subarachnoid hemorrhage: diagnosis, causes and management. Brain 2001, 124(Pt 2):249–278.

    Article  PubMed  Google Scholar 

  11. Edlow JA, Caplan LR: Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000, 342:29–36.

    Article  PubMed  CAS  Google Scholar 

  12. Morgenstern LB, Luna-Gonzales H, Huber JC Jr, et al.: Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 1998, 32(3 Pt 1):297–304.

    PubMed  CAS  Google Scholar 

  13. van der Wee N, Rinkel GJ, Hasan D, van Gijn J: Detection of subarachnoid hemorrhage on early CT: is lumbar puncture still needed after a negative scan? J Neurol Neurosurg Psychiatry 1995, 58:357–359.

    Article  PubMed  Google Scholar 

  14. Vermeulen M, Hasan D, Blijenberg BG, et al.: Xanthochromia after subarachnoid hemorrhage needs no revisitation. J Neurol Neurosurg Psychiatry 1989, 52:826–828.

    Article  PubMed  CAS  Google Scholar 

  15. Polmear A: Sentinel headaches in aneurysmal subarachnoid hemorrhage: what is the true incidence? A systematic review. Cephalalgia 2003, 23:935–941.

    Article  PubMed  CAS  Google Scholar 

  16. Wardlaw JM, White PM: The detection and management of unruptured intracranial aneurysms. Brain 2000, 123(Pt 2):205–221.

    Article  PubMed  Google Scholar 

  17. Fridriksson S, Hillman J, Landtblom AM, Boive J: Education of referring doctors about sudden onset headache in subarachnoid hemorrhage. A prospective study. Acta Neurol Scand 2001, 103:238–242.

    Article  PubMed  CAS  Google Scholar 

  18. Harling DW, Peatfield RC, Van Hille PT, Abbott RJ: Thunderclap headache: is it migraine? Cephalalgia 1989, 9:87–90.

    Article  PubMed  CAS  Google Scholar 

  19. Markus HS: A prospective follow up of thunderclap headache mimicking subarachnoid hemorrhage. J Neurol Neurosurg Psychiatry 1991, 54:1117–1118.

    Article  PubMed  CAS  Google Scholar 

  20. Wijdicks EF, Kerkhoff H, van Gijn J: Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid hemorrhage. Lancet 1988, 2:68–70.

    Article  PubMed  CAS  Google Scholar 

  21. Melo TP, Pinto AN, Ferro JM: Headache in intracerebral hematomas. Neurology 1996, 47:494–500.

    PubMed  CAS  Google Scholar 

  22. van der Hoop RG, Vermeulen M, van Gijn J: Cerebellar hemorrhage: diagnosis and treatment. Surg Neurol 1998, 29:6–10.

    Article  Google Scholar 

  23. Kotwica Z, Brzezinski J: Chronic subdural hematoma presenting as spontaneous subarachnoid hemorrhage. Report of six cases. J Neurosurg 1985, 63:691–692.

    Article  PubMed  CAS  Google Scholar 

  24. Wintzen AR, Tijssen JG. Subdural hematoma and oral anticoagulant therapy. Arch Neurol 1982, 39:69–72.

    PubMed  CAS  Google Scholar 

  25. Tomaras C, Horowitz BL, Harper RL: Spontaneous clivus hematoma: case report and literature review. Neurosurgery 1995, 37:123–124.

    Article  PubMed  CAS  Google Scholar 

  26. Schievink WI, Thompson RC, Loh CT, Maya MM: Spontaneous retroclival hematoma presenting as a thunderclap headache. Case report. J Neurosurg 2001, 95:522–524.

    Article  PubMed  CAS  Google Scholar 

  27. Bousser MG, Russell RR: Cerebral Venous Thrombosis. London: WB Saunders; 1999.

    Google Scholar 

  28. Terazzi E, Mittino D, Ruda R, et al.: Cerebral venous thrombosis: a retrospective multicentre study of 48 patients. Neurol Sci 2005, 25:311–315.

    Article  PubMed  CAS  Google Scholar 

  29. Cumurciuc R, Crassard I, Sarov M, et al.: Headache as the only neurological sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry 2005, 76:1084–1087.

    Article  PubMed  CAS  Google Scholar 

  30. de Brujin SF, Stam J, Kappelle LJ: Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group. Lancet 1996, 348:1623–1625.

    Article  Google Scholar 

  31. Chiras J, Bousser MG, Meder JF, et al.: CT in cerebral thrombophlebitis. Neuroradiology 1985, 27:145–154.

    Article  PubMed  CAS  Google Scholar 

  32. Biousse V, Mitsias P: Carotid and vertebral artery pain. In The Headaches, edn 3. Edited by Olesen J, Goadsby P, Ramadan N, et al.: Philadelphia: Lippincott Williams & Wilkins; 2006:911–918.

    Google Scholar 

  33. Silbert PL, Mokri B, Schievink WI: Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology 1995, 45:1517–1522.

    PubMed  CAS  Google Scholar 

  34. Biousse V, D’Anglejan-Chatillon J, Massiou H, Bousser MG: Head pain in non-traumatic carotid artery dissection: a series of 65 patients. Cephalalgia 1994, 14:33–36.

    Article  PubMed  CAS  Google Scholar 

  35. Mohr JP, Caplan LR, Melski JW, et al.: The Harvard Cooperative Stroke Registry: a prospective registry. Neurology 1978, 28:754–762.

    PubMed  CAS  Google Scholar 

  36. Ferro JM, Melo TP, Oliveira V, et al.: A multivariate study of headache associated with ischemic stroke. Headache 1995, 35:315–319.

    Article  PubMed  CAS  Google Scholar 

  37. Vestergaard K, Andersen G, Nielsen MI, Jensen TS: Headache in stroke. Stroke 1993, 24:1621–1624.

    PubMed  CAS  Google Scholar 

  38. Bousser MG, Welch KM: Relation between migraine and stroke. Lancet 2005, 4:533–542.

    Article  Google Scholar 

  39. Schwedt TJ, Dodick DW: Thunderclap stroke: embolic cerebellar infarcts presenting as thunderclap headache. Headache 2006, In press.

  40. Reid RL, Quigley ME, Yen SS: Pituitary apoplexy. A review. Arch Neurol 1985, 42:712–719.

    PubMed  CAS  Google Scholar 

  41. Mohr G, Hardy J: Hemorrhage, necrosis, and apoplexy in pituitary adenomas. Surg Neurol 1982, 18:181–189.

    Article  PubMed  CAS  Google Scholar 

  42. Dodick DW, Wijdicks EF: Pituitary apoplexy presenting as a thunderclap headache. Neurology 1998, 50:1510–1511.

    PubMed  CAS  Google Scholar 

  43. Embil JM, Kramer M, Kinnear S, Light RB: A blinding headache. Lancet 1997, 350:182.

    Article  PubMed  CAS  Google Scholar 

  44. Tang-Wai DF, Phan TG, Wijdicks EF: Hypertensive encephalopathy presenting with thunderclap headache. Headache 2001, 41:198–200.

    Article  PubMed  CAS  Google Scholar 

  45. Shimada J, Takeda N, Yamauchi S, et al.: Reversible posterior leukoencephalopathy syndrome: experience in 3 cases [Japanese]. No To Shinkei 2004, 56:1036–1041.

    PubMed  Google Scholar 

  46. Dodick DW, Eross EJ, Drazkowski JF, Ingall TJ: Thunderclap headache associated with reversible vasospasm and posterior leukoencephalopathy syndrome. Cephalalgia 2003, 23:994–997.

    Article  PubMed  CAS  Google Scholar 

  47. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P: Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996, 27:144–147.

    PubMed  CAS  Google Scholar 

  48. Hinchey J, Chaves C, Appignani B, et al.: A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996, 334:494–500.

    Article  PubMed  CAS  Google Scholar 

  49. Schwartz RB: Hyperfusion encephalopathies: hypertensive encephalopathy and related conditions. Neurologist 2002, 8:22–34.

    Article  PubMed  Google Scholar 

  50. Schwartz RB, Mulkern RV, Gudbjartsson H, Jolesz F: Diffusion-weighted MR imaging in hypertensive encephalopathy: clues to pathogenesis. Am J Neuroradiol 1998, 19:859–862.

    PubMed  CAS  Google Scholar 

  51. Calabrese LH, Gragg LA, Furlan AJ: Benign angiopathy: a distinct subset of angiographically defined primary angiitis of the central nervous system. J Rheumatol 1993, 20:2046–2050.

    PubMed  CAS  Google Scholar 

  52. Hajj-Ali RA, Furlan A, Abou-Chebel A, Calabrese LH: Benign angiopathy of the central nervous system: cohort of 16 patients with clinical course and long-term followup. Arthritis Rheum 2002, 47:662–669.

    Article  PubMed  Google Scholar 

  53. Call GK, Fleming MC, Sealfon S, et al.: Reversible cerebral segmental vasoconstriction. Stroke 1988, 19:1159–1170.

    PubMed  CAS  Google Scholar 

  54. Singhal AB, Bernstein RA: Postpartum angiopathy and other cerebral vasoconstriction syndromes. Neurocrit Care 2005, 3:91–97.

    Article  PubMed  Google Scholar 

  55. Calabrese LH, Mallek JA: Primary angiitis of the central nervous system. Report of 8 new cases, review of the literature, and proposal for diagnostic criteria. Medicine (Baltimore) 1988, 67:20–39.

    CAS  Google Scholar 

  56. Pomper MG, Miller TJ, Stone JH, et al.: CNS vasculitis in autoimmune disease: MR imaging findings and correlation with angiography. Am J Neuroradiol 1999, 20:75–85.

    PubMed  CAS  Google Scholar 

  57. Lu SR, Liao YC, Fuh JL, et al.: Nimodipine for treatment of primary thunderclap headache. Neurology 2004, 62:1414–1416.

    PubMed  CAS  Google Scholar 

  58. Mokri B: Headaches caused by decreased intracranial pressure: diagnosis and management. Curr Opin Neurol 2003, 16:319–326.

    Article  PubMed  Google Scholar 

  59. Schievink WI, Wijdicks EF, Meyer FB, Sonntag VK: Spontaneous intracranial hypotension mimicking aneurysmal subarachnoid hemorrhage. Neurosurgery 2001, 48:513–516, discussion 516–517.

    Article  PubMed  CAS  Google Scholar 

  60. Kelly R: Colloid cysts of the third ventricle, analysis of twenty-nine cases. Brain 1951, 74:23–65.

    Article  PubMed  CAS  Google Scholar 

  61. Michels LG, Rutz D: Colloid cysts of the third ventricle. A radiologic-pathologic correlation. Arch Neurol 1982, 39:640–643.

    PubMed  CAS  Google Scholar 

  62. Young WB, Silberstein SD: Paroxysmal headache caused by colloid cyst of the third ventricle: case report and review of the literature. Headache 1997, 37:15–20.

    Article  PubMed  CAS  Google Scholar 

  63. Headache Classification Committee of The International Headache Society: The International Classification of Headache Disorders (second edition). Cephalalgia 2004, 24:1–195.

    Google Scholar 

  64. Edvinsson L, Gulbenkian S, Barroso CP, et al.: Innervation of the human middle meningeal artery: immunohistochemistry, ultrastructure, and role of endothelium for vasomotility. Peptides 1998, 19:1213–1225.

    Article  PubMed  CAS  Google Scholar 

  65. Edvinsson L, Owman C: Cerebrovascular nerves and vasomotor receptors. In Cerebral Arterial Spasm. Edited by Wilkins RH. Baltimore: Williams & Wilkins; 1980;30–36.

    Google Scholar 

  66. Endo S, Suzuki J: Experimental cerebral vasospasm after subarachnoid hemorrhage. Participation of adrenergic nerves in cerebral vessel wall. Stroke 1979, 10:703–711.

    PubMed  CAS  Google Scholar 

  67. Armstrong FS, Hayes GJ: Segmental cerebral arterial constriction associated with pheochromocytoma: report of a case with arteriograms. J Neurosurg 1961, 18:843–846.

    Article  PubMed  CAS  Google Scholar 

  68. Trommer BL, Homer D, Mikhael MA: Cerebral vasospasm and eclampsia. Stroke 1988, 19:326–329.

    PubMed  CAS  Google Scholar 

  69. Kye BR, Fainstat M: Cerebral vasculitis associated with cocaine abuse. JAMA 1987, 258:2104–2106.

    Article  Google Scholar 

  70. Raynor RB, Ross G: Arteriography and vasospasm. The effects of intracarotid contrast media on vasospasm. J Neurosurg 1960, 17:1055–1061.

    Article  PubMed  CAS  Google Scholar 

  71. Alberico RA, Patel M, Casey S, et al.: Evaluation of the circle of Willis with three-dimensional CT angiography in patients with suspected intracranial aneurysms. Am J Neuroradiol 1995, 16:1571–1578, discussion 1579–1580.

    PubMed  CAS  Google Scholar 

  72. Hope JK, Wilson JL, Thomson FJ: Three-dimensional CT angiography in the detection and characterization of intracranial berry aneurysms. Am J Neuroradiol 1996, 17:439–445.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Headache Group, Institute of Neurology, Queen Square, London, WC1N 3BG, UK

    Manjit S. Matharu MRCP

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  1. Manjit S. Matharu MRCP
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  2. Todd J. Schwedt MD
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  3. David W. Dodick MD
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Correspondence to Manjit S. Matharu MRCP.

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Matharu, M.S., Schwedt, T.J. & Dodick, D.W. Thunderclap headache: An approach to a neurologic emergency. Curr Neurol Neurosci Rep 7, 101–109 (2007). https://doi.org/10.1007/s11910-007-0004-8

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