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