2 In our emergency headache centre, out of a total of 8000 patients each year, about 120 present with thunderclap headache. A prompt diagnosis is crucial, but these patients must be distinguished from patients with non-haemorrhagic benign thunderclap headache (BTH). In 2–10% of cases, the headache is of thunderclap character. The Ottawa Subarachnoid Hemorrhage Rule may be used in neurologically intact patients presenting with acute, nontraumatic headaches that reach max intensity within one hour. Thunderclap headaches are dramatic. This site complies with the HONcode standard for trustworthy health information: verify here. Patients with thunderclap headache must be evaluated emergently and comprehensively to rule out underlying disorders that can be associated with high mortality and morbidity, determine the cause for the Devenney E, et al. The international classification of headache disorders, 3rd edition (beta version). [1][7], Reversible cerebral vasoconstriction syndrome, "Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache", "A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based? In other cases, a variety of potentially life-threatening conditions might be responsible, including: Thunderclap headaches care at Mayo Clinic. Thunderclap headache (TCH) is a sudden severe headache that peaks to maximum intensity within 1 minute. [1][2] Although approximately 75% are attributed to "primary" headaches—headache disorder, non-specific headache, idiopathic thunderclap headache, or uncertain headache disorder—the remainder are secondary to other causes, which can include some extremely dangerous acute conditions, as well as infections and other conditions. The pain usually precedes other problems that are caused by impaired blood flow through the artery into the brain; these may include visual symptoms, weakness of part of the body, and other abnormalities depending on the vessel affected. This is called a subarachnoid hemorrhage.Onset is usually sudden without prodrome, classically presenting as a "thunderclap headache" worse than previous headaches. SeizuresThese signs and symptoms might reflect the underlying cause. Mayo Clinic. In many cases, there are no other abnormalities, but the various causes of thunderclap headaches may lead to a number of neurological symptoms. The Journal of Headache and Pain. Approximately 75% are attributed to "primary" headaches: headache disorder, non-specific headache, idiopathic thunderclap headache or uncertain headache disorder. Allscripts EPSi. Headache is a chief complaint that accounts for 2% of emergency department (ED) visits. If this is normal, a lumbar puncture is performed, as a small proportion of SAH is missed on CT and can still be detected as xanthochromia. The term was first used in a patient who had three episodes of “intense sentinel headache of sudden onset” before an unruptured aneurysm was found [].A later study following 71 patients for an average of 3.3 years reported no SAH, which led to the concept of “benign TCH” []. Symptoms include pain that: 1. The remainder is attributed to secondary causes: vascular problems, infections and various other conditions. While other types of headache build up slowly, thunderclap headaches tend to … rhage (SAH), which accounts for 4% to 12% of ED patients with a thunderclap headache.3–6 Current clinical practice calls for a noncontrast computed tomography (CT) of the brain fol-lowed by a lumbar puncture (LP) if the CT scan is negative to exclude SAH.7–10 This is because the sensitivity of CT scans Headache induced by SAH is typically severe and abrupt, commonly described as a “thunderclap” headache or the “worst headache of life.” While the first diagnostic test of choice in this situation is cranial CT without contrast, a small proportion of cases present with normal or non- diagnostic imaging findings. SAH has been observed in up to 25% of TCH patients. [1], Carotid artery dissection and vertebral artery dissection (together cervical artery dissection), in which a tear forms inside the wall of the blood vessels that supply the brain, often causes pain on the affected side of the head or neck. [3] The remainder are secondary to a number of conditions, including:[1][3], The most important of the secondary causes are subarachnoid hemorrhage, cerebral venous sinus thrombosis, and dissection of an artery in the neck. A single copy of these materials may be reprinted for noncommercial personal use only. It has numerous potential etiologies, the most concerning of which is subarachnoid hemorrhage (SAH) due to high morbidity and mortality. [3] Usually, further investigations are performed to identity the underlying cause.[1]. 2014 Aug 14;15:49. Advertising revenue supports our not-for-profit mission. Subarachnoid hemorrhage is the most commonly identified etiology for this headache, however, other secondary etiologies should be considered. Prospective data refine the understanding of thunderclap headaches that may accompany subarachnoid hemorrhage. Make a donation. A headache is called "thunderclap headache" if it is severe in character and reaches maximum severity within seconds to minutes of onset. Classic presentation (highly suggestive of Subarachnoid Hemorrhage) Thunderclap Headache; Vomiting; Altered Level of Consciousness; Headache Characteristics: Severe, sudden, atypical and unrelenting. If this is normal, a lumbar puncture is performed, as a small proportion of SAH is missed on CT and can still be detected as xanthochromia. “A thunderclap headache needs to be considered an emergency,” he said. Magnetic resonance angiography (MRA) may be useful in identifying problems with the arteries (such as dissection), and magnetic resonance venography (MRV) identifies venous thrombosis. [1], Cerebral venous sinus thrombosis, thrombosis of the veins of the brain, usually causes a headache that reflects raised intracranial pressure and is therefore made worse by anything that makes the pressure rise further, such as coughing. Thunderclap headache is frequently associated with serious vascular intracranial vascular disorders, particularly subarachnoid haemorrhage: it is mandatory to exclude this and a range of other such conditions including intracerebral haemorrhage, cerebral venous thrombosis, unruptured vascular malformation (mostly aneurysm), arterial dissection (intra- and extracranial), reversible cerebral … Dec. 17, 2017. Symptoms include pain that: Thunderclap headaches might be accompanied by other signs and symptoms, such as: These signs and symptoms might reflect the underlying cause. Olesen J, et al. Bleeding between the brain and membranes covering the brain (subarachnoid hemorrhage), A tear in the lining of an artery that supplies blood to the brain, Leaking of cerebrospinal fluid — usually due to a tear of the covering around a nerve root in the spine, Death of tissue or bleeding in the pituitary gland, Severe elevation in blood pressure (hypertensive crisis), Infection such as meningitis or encephalitis. If an aneurysm ruptures, blood leaks into the space around the brain. Thunderclap headache (TCH) is a well-known presentation of subarachnoid hemorrhage (SAH). This means that an extremely thorough workup needs to be done on a person with a thunderclap headache to make s… It is not usually necessary to proceed to cerebral angiography, a more precise but invasive investigation of the brain's blood vessels, if MRA and MRV are normal. Seek emergency medical attention for a thunderclap headache. The clinical decision rule is 100% sensitive, with a specificity of 15%. A thunderclap headache is a severe headache with a rapid onset. PURPOSE OF REVIEW: A thunderclap headache is a very severe headache that reaches its maximum intensity within 1 minute. This content does not have an English version. Symptoms of a subarachnoid hemorrhage differ depending on the site and size of the aneurysm. It appeared to be thunderclap headache that was prompting physicians to over-investigate. None of those resulted in NOT investigating patients with SAH, but most of the time it was over-investigating. Thunderclap headache (TCH) is head pain that begins suddenly and is severe at onset. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Symptoms of a ruptured aneurysm can include: A thunderclap headache is the primary complaint in 94-100% of patients and is often the only presenting symptom.26 Although many diagnoses can present with a thunderclap headache, RCVS along with SAH are among the few that present primarily with a thunderclap. Fever 3. The International Headache Society defines a primary thunderclap headache as a “high-intensity headache of abrupt onset mimicking that of a ruptured cerebral aneurysm, in the absence of any intracranial pathology." This content does not have an Arabic version. Sentinel headache, reversible cerebral vasoconstriction syndrome, arterial dissection, cerebral venous sinus thrombosis, pituitary … Approach to the patient with thunderclap headache. A thunderclap headache is a headache that is severe and has a sudden onset. Thunderclap headaches are uncommon, but they can warn of potentially life-threatening conditions — usually having to do with bleeding in and around the brain. Although it is a serious, life-threatening condition, the presentation of SAH has not been well defined by the literature. The term thunderclap headache is used to decribe a severe headache of instantaneous onset—one minute at the most. [1], The most important initial investigation is computed tomography of the brain, which is very sensitive for subarachnoid hemorrhage. The headache typically persists for several days. Cephalia. Sudden onset Thunderclap Headache "Worst Headache of my life" (+LR 1.20, less predictive than other red flags as below); Headache reaches maximum intensity in minutes (<10 to 60 minutes) Thunderclap headaches are dramatic. Subarachnoid hemorrhage (SAH) is one condition that emergency physicians must diagnose, as it is serious and potentially deadly. ", "Risk factors for subarachnoid hemorrhage", https://en.wikipedia.org/w/index.php?title=Thunderclap_headache&oldid=978196992, Creative Commons Attribution-ShareAlike License, Primary cough headache, primary exertional headache, and primary, This page was last edited on 13 September 2020, at 13:45. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic. [5][6] The term "thunderclap headache" was introduced in 1986 in a report by John Day and Neil Raskin, neurologists at the University of California, San Francisco, in a report of a 42-year-old woman who had experienced several sudden headaches and was found to have an aneurysm that had not ruptured. © 1998-2021 Mayo Foundation for Medical Education and Research (MFMER). Serious causes of secondary thunderclap headaches include subarachnoid hemorrhage, cervical artery dissection, stroke, and a hypertensive crisis. Sensitive, with a rapid onset of these severe headaches peaks within 60 seconds are. 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