thunderclap headache

Etiology

• primary headaches
  • primary stabbing headache 'ice-pick' headache
  • primary cough headache
  • primary exertional headache
  • primary sexual headache
  • primary thunderclap headache
• secondary headaches
  • vascular disorder identified in 30-80% of patients
    • subarachnoid hemorrhage (25%) - most common cause
    • intraparenchymal hemorrhagic stroke
    • cerebral arterial thrombosis (ischemic stroke) *
      • transient ischemic attack*
    • cerebral venous thrombosis
    • dural sinus thrombosis
    • arterial dissection
      • carotid artery dissection
      • vertebral artery dissection
      • basilar artery dissection
    • sentinel bleeding from unruptured intracranial aneurysm
    • reversible cerebral vasoconstriction syndrome* (2nd most common cause)
    • pituitary apoplexy
  • spontaneous intracranial hypotension
  • posterior reversible encephalopathy syndrome
  • colloid cyst occlusion of the 3rd ventricle
• idiopathic

* ischemic stroke & TIA are generally painless

Pathology

• 85% of thunderclap headaches due to subarachnoid hemorrhage result from previously unidentified cerebral aneurysms

Clinical manifestations

• severe, explosive headache at maximal intensity within 60 seconds of onset
• case presentation of abrupt-onset severe headache lasting 6-8 hours
• may occur in isolation or may be recurrent over days to weeks
• may begin spontaneously
• may be triggered by
  • Valsalva maneuver
  • physical exertion, including sexual intercourse
  • shower

Diagnostic procedures

• lumbar puncture (after head CT)
  • CSF analysis
    • no evidence of subarachnoid hemorrhage

Radiology

• non-contrast CT of the head (emergency)
• magnetic resonance imaging (MRI) angiography
• CT angiography

Management

• normalization of blood pressure
• calcium channel blocker 1st line for thunderclap headache due to reversible cerebral vasoconstriction syndrome
  • nimodipine, verapamil
• indomethacin may be appropriate after intracranial hemorrhage or impending intracranial hemorrhage has been ruled out

More general terms

• headache

More specific terms

• reversible cerebral vasoconstriction syndrome (Call-Fleming syndrome)