Subarachnoid hemorrhage (SAH) is one condition that emergency physicians must diagnose, as it is serious and potentially deadly. 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." The remainder is attributed to secondary causes: vascular problems, infections and various other conditions. 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. The clinical decision rule is 100% sensitive, with a specificity of 15%. Subarachnoid hemorrhage is the most commonly identified etiology for this headache, however, other secondary etiologies should be considered. Cephalia. Allscripts EPSi. Magnetic resonance angiography (MRA) may be useful in identifying problems with the arteries (such as dissection), and magnetic resonance venography (MRV) identifies venous thrombosis. 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 thunderclap headache, and initiate targeted therapy. While other types of headache build up slowly, thunderclap headaches tend to … Approximately 75% are attributed to "primary" headaches: headache disorder, non-specific headache, idiopathic thunderclap headache or uncertain headache disorder. Symptoms of a subarachnoid hemorrhage differ depending on the site and size of the aneurysm. A systematic review of causes of sudden and severe headache (thunderclap headache): Should lists be evidence based? The classic teaching in medical school is that a “thunderclap” headache is pathognomonic for subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm. 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) 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. This content does not have an English version. "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. Peaks within 60 seconds 3. Mayo Clinic is a not-for-profit organization. ", "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. QuizzCauses de Thunderclap headache ? Also, according to the IHS "evidence that thunderclap headache exists as a primary disorder is rare." [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. [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. Thunderclap headache (TCH) is head pain that begins suddenly and is severe at onset. [1][4], In subarachnoid hemorrhage, there may be syncope (transient loss of consciousness), seizures, meningism (neck pain and stiffness), visual symptoms, and vomiting. Approach to the patient with thunderclap headache. In 2–10% of cases, the headache is of thunderclap character. A headache is called "thunderclap headache" if it is severe in character and reaches maximum severity within seconds to minutes of onset. [3], The importance of severe headaches in the diagnosis of subarachnoid hemorrhage has been known since the 1920s, when London neurologist Charles Symonds described the clinical syndrome. The pain of these severe headaches peaks within 60 seconds. Headache is a chief complaint that accounts for 2% of emergency department (ED) visits. Dec. 17, 2017. [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. SAH has been observed in up to 25% of TCH patients. It is defined as a severe headache that takes seconds to minutes to reach maximum intensity. However, only 11-25% of TCHs are due to SAH. Its primary symptom—a severe, abrupt headache known as a “thunderclap” headache—can easily be mistaken for other conditions, making it difficult to assign the correct degree of urgency needed for effective treatment. 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” []. [ncbi.nlm.nih.gov] Numerous etiologies for thunderclap headaches have been identified, with the most common causes being subarachnoid hemorrhage and reversible cerebral vasoconstriction syndrome. This content does not have an Arabic version. [1], Incidence of thunderclap headache has been estimated at 43 per 100,000 people every year. Thunderclap headache (TCH) refers to a severe headache of sudden onset. Subarachnoid hemorrhage. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 50–70% of people with subarachnoid hemorrhage have an isolated headache without decreased level of consciousness. 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. Thunderclap headaches live up to their name, striking suddenly like a clap of thunder. Olesen J, et al. This site complies with the HONcode standard for trustworthy health information: verify here. [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. Advertising revenue supports our not-for-profit mission. A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based? There's no obvious cause for some thunderclap headaches. 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 … Serious causes of secondary thunderclap headaches include subarachnoid hemorrhage, cervical artery dissection, stroke, and a hypertensive crisis. [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. The most important initial investigation is computed tomography of the brain, which is very sensitive for subarachnoid hemorrhage. Thunderclap headache is an uncommon type of headache, but recognition and diagnosis are important because of the possibility of a serious underlying brain disorder. [1], The most important initial investigation is computed tomography of the brain, which is very sensitive for subarachnoid hemorrhage. 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. © 1998-2021 Mayo Foundation for Medical Education and Research (MFMER). Nov. 12, 2019. Thunderclap headache (TCH) is an excruciating headache that reaches maximal intensity within a minute. The international classification of headache disorders, 3rd edition (beta version). The Ottawa Subarachnoid Hemorrhage Rule may be used in neurologically intact patients presenting with acute, nontraumatic headaches that reach max intensity within one hour. 2 “A person who develops a severe headache with sexual activity or orgasm can also have a bleed, aneurysm, or … 2013;33:629. Thunderclap headache (TCH) is a sudden severe headache that peaks to maximum intensity within 1 minute. It has numerous potential etiologies, the most concerning of which is subarachnoid hemorrhage (SAH) due to high morbidity and mortality. Fever 3. Conditions that may be associated with thunderclap headaches include: strokes migraines head injury high blood pressure 2014 Aug 14;15:49. Although it is a serious, life-threatening condition, the presentation of SAH has not been well defined by the literature. Although TCH initially referred to pain associated with an unruptured intracranial aneurysm [ 1 ], multiple etiologies are now recognized [ 2 ] (table 1). Severe and sudden onset headache may indicate subarachnoid hemorrhage due to aneurysmal rupture or a sentinel bleed from a leaking aneurysm. It appeared to be thunderclap headache that was prompting physicians to over-investigate. A single copy of these materials may be reprinted for noncommercial personal use only. Purpose of review: A thunderclap headache is a very severe headache that reaches its maximum intensity within 1 minute. Devenney E, et al. Thunderclap headaches are uncommon, but they can warn of potentially life-threatening conditions — usually having to do with bleeding in and around the brain. Accounting for 1% of headaches, SAH is most commonly due to arterial aneurysm rupture 1-3. The headache characteristics and associated features at onset in subarachnoid haemorrhage and benign thunderclap headache were … 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. 2014;15:49. This is called a subarachnoid hemorrhage.Onset is usually sudden without prodrome, classically presenting as a "thunderclap headache" worse than previous headaches. Check out these best-sellers and special offers on books and newsletters from 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. Seek emergency medical attention for a thunderclap headache. The few under-investigated patients happened when neck pain or stiffness … 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 2 In our emergency headache centre, out of a total of 8000 patients each year, about 120 present with thunderclap headache. Neurology Reviews. [1][2], If both investigations are normal, the specific description of the headache and the presence of other abnormalities may prompt further tests, usually involving magnetic resonance imaging (MRI). All rights reserved. Brown AY. The Journal of Headache and Pain. Prospective data refine the understanding of thunderclap headaches that may accompany subarachnoid hemorrhage. Thunderclap headaches are dramatic. Sentinel headache, reversible cerebral vasoconstriction syndrome, arterial dissection, cerebral venous sinus thrombosis, pituitary … The headache characteristics and associated features at onset in subarachnoid haemorrhage and benign thunderclap headache were studied to delineate the range of early features in these conditions. Altered mental state 2. In other cases, a variety of potentially life-threatening conditions might be responsible, including: Thunderclap headaches care at Mayo Clinic. Approximately 75% are attributed to "primary" headaches: headache disorder, non-specific headache, idiopathic thunderclap headache or uncertain headache disorder. Mayo Clinic. In most cases there are other neurological abnormalities, such as seizures and weakness of part of the body, but in 15–30% the headache is the only abnormality. See our safety precautions in response to COVID-19. Subarachnoid hemorrhage is the most commonly identified etiology for this headache, however, other secondary etiologies should be considered. 5,6 What else should the EP think of when a patient presents with a TCH? Make a donation. The headache typically persists for several days. Symptoms of a ruptured aneurysm can include: Thunderclap headaches are dramatic. Most importantly, SAH, other intracranial hemorrhages, or cerebral venous thrombosis should be excluded by CT, or, if the CT scan is negative, by examining the CSF. Its explosive and unexpected nature is likened to a "clap of thunder." Classic presentation (highly suggestive of Subarachnoid Hemorrhage) Thunderclap Headache; Vomiting; Altered Level of Consciousness; Headache Characteristics: Severe, sudden, atypical and unrelenting. [3] Usually, further investigations are performed to identity the underlying cause.[1]. https://www.uptodate.com/contents/search. The term thunderclap headache is used to decribe a severe headache of instantaneous onset—one minute at the most. None of those resulted in NOT investigating patients with SAH, but most of the time it was over-investigating. Thunderclap headaches are severe headaches coming on full force in less than a minute, lasting at least 5 minutes, and often appearing without any trigger. 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. This means that an extremely thorough workup needs to be done on a person with a thunderclap headache to make s… A prompt diagnosis is crucial, but these patients must be distinguished from patients with non-haemorrhagic benign thunderclap headache (BTH). Symptoms include pain that: 1. Mayo Clinic does not endorse companies or products. Strikes suddenly and severely 2. A thunderclap headache is a headache that is severe and has a sudden onset. 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. thunderclap HA is not reported as abrupt (patient may not remember event well) “Worst or first” headache of one’s life that is instantaneously maximal at onset (“thunderclap” after lightening strike) HA responds well to non-narcotic analgesics 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 Seek immediate medical attention for any headache that comes on suddenly and severely. J Headache Pain. SeizuresThese signs and symptoms might reflect the underlying cause. PURPOSE OF REVIEW: A thunderclap headache is a very severe headache that reaches its maximum intensity within 1 minute. SAH Symptoms and Signs CLASSIC NOT-SO-CLASSIC Abrupt onset of severe headache (HA), i.e. 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. [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? Can be accompanied by nausea or vomitingThunderclap headaches might be accompanied by other signs and symptoms, such as: 1. A thunderclap headache is a severe headache with a rapid onset. One third of patients with aneurysmal subarachnoid haemorrhage (ASAH) present with headache only. “A thunderclap headache needs to be considered an emergency,” he said. Schwedt TJ, et al. Abstract. 2018 April;26(4):15 . If an aneurysm ruptures, blood leaks into the space around the brain. Thunderclap headache (TCH) is a well-known presentation of subarachnoid hemorrhage (SAH). 1 Estimated incidence is about 43 per 100 000 adults per year in the developed world. Vaccine updates, safe care and visitor guidelines, and trusted coronavirus information, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, See our safety precautions in response to COVID-19, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter — Digital Edition, FREE book offer – Mayo Clinic Health Letter, New Year Special -  40% off – Mayo Clinic Diet Online. 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To reach maximum intensity, other secondary etiologies should be considered and might... Is about 43 per 100,000 people every year signs CLASSIC NOT-SO-CLASSIC Abrupt onset of severe headache that reaches maximal within... Best-Sellers and special offers on books and newsletters from Mayo Clinic per 100 000 adults per in... Reprinted for noncommercial personal use only CLASSIC NOT-SO-CLASSIC Abrupt onset of severe headache that prompting!, cervical artery dissection, stroke, and a hypertensive crisis underlying cause. [ 1,..., idiopathic thunderclap headache exists as a `` thunderclap headache ( HA ), i.e may accompany subarachnoid (... Not-So-Classic Abrupt onset of severe headache ( thunderclap headache exists as a `` clap of thunder. live up their... Must diagnose, as it is a serious, life-threatening condition, the presentation of SAH been!