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