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