Thunderclap headache

Last updated
Thunderclap headache
Other namesLone acute severe headache
Specialty Neurology

A thunderclap headache is a headache that is severe and has a sudden onset. It is defined as a severe headache that takes seconds to minutes to reach maximum intensity. [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] Usually, further investigations are performed to identity the underlying cause. [1]

Contents

Signs and symptoms

A headache is called "thunderclap headache" if it is severe in character and reaches maximum severity within seconds to minutes of onset. In many cases, there are no other abnormalities, but the various causes of thunderclap headaches may lead to a number of neurological symptoms.

Causes

Approximately 75% are attributed to "primary" headaches: headache disorder, non-specific headache, idiopathic thunderclap headache or uncertain headache disorder. [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. [1] [4]

In subarachnoid hemorrhage, there may be syncope (transient loss of consciousness), seizures, meningism (neck pain and stiffness), visual symptoms, and vomiting. 50–70% of people with subarachnoid hemorrhage have an isolated headache without decreased level of consciousness. The headache typically persists for several days. [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. In 2–10% of cases, the headache is of thunderclap character. 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. [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 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. [1]

Diagnosis

The most important initial investigation is computed tomography of the brain, which is very sensitive for subarachnoid hemorrhage. 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] [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). Magnetic resonance angiography (MRA) may be useful in identifying problems with the arteries (such as dissection), and magnetic resonance venography (MRV) identifies venous thrombosis. 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. [1]

Epidemiology

Incidence of thunderclap headache has been estimated at 43 per 100,000 people every year. Approximately 75% are attributed to "primary" headaches: headache disorder, non-specific headache, idiopathic thunderclap headache or uncertain headache disorder. The remainder is attributed to secondary causes: vascular problems, infections and various other conditions. [3]

History

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. [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] [7]

Related Research Articles

Idiopathic intracranial hypertension Human disease

Idiopathic intracranial hypertension (IIH), previously known as pseudotumor cerebri and benign intracranial hypertension, is a condition characterized by increased intracranial pressure without a detectable cause. The main symptoms are headache, vision problems, ringing in the ears with the heartbeat, and shoulder pain. Complications may include vision loss.

Headache Pain in head or neck

Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. Frequent headaches can affect relationships and employment. There is also an increased risk of depression in those with severe headaches.

Intracranial aneurysm Cerebrovascular disorder

Intracranial aneurysm, also known as brain aneurysm, is a cerebrovascular disorder in which weakness in the wall of a cerebral artery or vein causes a localized dilation or ballooning of the blood vessel.

Cerebrovascular disease Condition that affects the arteries that supply the brain

Cerebrovascular disease includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation. Arteries supplying oxygen and nutrients to the brain are often damaged or deformed in these disorders. The most common presentation of cerebrovascular disease is an ischemic stroke or mini-stroke and sometimes a hemorrhagic stroke. Hypertension is the most important contributing risk factor for stroke and cerebrovascular diseases as it can change the structure of blood vessels and result in atherosclerosis. Atherosclerosis narrows blood vessels in the brain, resulting in decreased cerebral perfusion. Other risk factors that contribute to stroke include smoking and diabetes. Narrowed cerebral arteries can lead to ischemic stroke, but continually elevated blood pressure can also cause tearing of vessels, leading to a hemorrhagic stroke.

Intracranial pressure Pressure exerted by fluids inside the skull and on the brain

Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury (mmHg) and, at rest, is normally 7–15 mmHg for a supine adult. The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF.

Subarachnoid hemorrhage Bleeding into the subarachnoid space

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever, and sometimes seizures. Neck stiffness or neck pain are also relatively common. In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed.

Intracranial hemorrhage Hemorrhage, or bleeding, within the skull

Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds, subarachnoid bleeds, epidural bleeds, and subdural bleeds.

Sexual headache is a type of headache that occur in the skull and neck during sexual activity, including masturbation or orgasm. These headaches are usually benign, but occasionally are caused by intracranial hemorrhage and cerebral infarction, especially if the pain is sudden and severe. They may be caused by general exertion, sexual excitement, or contraction of the neck and facial muscles. Most cases can be successfully treated with medication.

Intraparenchymal hemorrhage intraparenchymal

Intraparenchymal hemorrhage (IPH) is one form of intracerebral bleeding in which there is bleeding within brain parenchyma. The other form is intraventricular hemorrhage (IVH).

Dural venous sinuses Venous channels in the dura mater

The dural venous sinuses are venous channels found between the endosteal and meningeal layers of dura mater in the brain. They receive blood from the cerebral veins, receive cerebrospinal fluid (CSF) from the subarachnoid space via arachnoid granulations, and mainly empty into the internal jugular vein.

Dural arteriovenous fistula

A dural arteriovenous fistula (DAVF) or Malformation, is an abnormal direct connection (fistula) between a meningeal artery and a meningeal vein or dural venous sinus.

Cavernous sinus thrombosis Human disease

Cavernous sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart. This is a rare disorder and can be of two types–septic cavernous thrombosis and aseptic cavernous thrombosis. Most commonly the form is of septic cavernous sinus thrombosis. The cause is usually from a spreading infection in the nose, sinuses, ears, or teeth. Staphylococcus aureus and Streptococcus are often the associated bacteria.

Vertebral artery dissection traumatic or nontraumatic vertebral artery rupture

Vertebral artery dissection (VAD) is a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. After the tear, blood enters the arterial wall and forms a blood clot, thickening the artery wall and often impeding blood flow. The symptoms of vertebral artery dissection include head and neck pain and intermittent or permanent stroke symptoms such as difficulty speaking, impaired coordination and visual loss. It is usually diagnosed with a contrast-enhanced CT or MRI scan.

Cerebral venous sinus thrombosis presence of acute thrombosis (a blood clot) in the dural venous sinuses, which drain blood from the brain.

Cerebral venous sinus thrombosis (CVST) is the presence of a blood clot in the dural venous sinuses, which drain blood from the brain. Symptoms may include headache, abnormal vision, any of the symptoms of stroke such as weakness of the face and limbs on one side of the body, and seizures.

Vascular myelopathy refers to an abnormality of the spinal cord in regard to its blood supply. The blood supply is complicated and supplied by two major vessel groups: the posterior spinal arteries and the anterior spinal arteries—of which the Artery of Adamkiewicz is the largest. Both the posterior and anterior spinal arteries run the entire length of the spinal cord and receive anastomotic (conjoined) vessels in many places. The anterior spinal artery has a less efficient supply of blood and is therefore more susceptible to vascular disease. Whilst atherosclerosis of spinal arteries is rare, necrosis in the anterior artery can be caused by disease in vessels originating from the segmental arteries such as atheroma or aortic dissection.

Cerebral vasculitis is vasculitis involving the brain and occasionally the spinal cord. It affects all of the vessels: very small blood vessels (capillaries), medium-size blood vessels, or large blood vessels. If blood flow in a vessel with vasculitis is reduced or stopped, the parts of the body that receive blood from that vessel begins to die. It may produce a wide range of neurological symptoms, such as headache, skin rashes, feeling very tired, joint pains, difficulty moving or coordinating part of the body, changes in sensation, and alterations in perception, thought or behavior, as well as the phenomena of a mass lesion in the brain leading to coma and herniation. Some of its signs and symptoms may resemble multiple sclerosis. 10% have associated bleeding in the brain.

Bonnet–Dechaume–Blanc syndrome disease

Bonnet–Dechaume–Blanc syndrome, also known as Wyburn-Mason syndrome, is a rare congenital disorder characterized by arteriovenous malformations of the brain, retina or facial nevi. The syndrome has a number of possible symptoms and can, more rarely, affect the skin, bones, kidneys, muscles, and gastrointestinal tract. When the syndrome affects the brain, people can experience severe headaches, seizures, acute stroke, meningism, and progressive neurological deficits due to acute or chronic ischaemia caused by arteriovenous shunting.

Behçet's disease is recognized as a disease that cause inflammatory perivasculitis, inflammation of the tissue around a blood or lymph vessel, in practically any tissue in the body. Usually, prevalent symptoms include canker sores or ulcers in the mouth and on the genitals, and inflammation in parts of the eye. In addition, patients experience severe headache and papulopustular skin lesions as well. The disease was first described in 1937 by a Turkish dermatologist, Dr. Hulusi Behçet. Behçet's disease is most prevalent in the Middle East and the Far East regions; however, it is rare in America regions.

Reversible cerebral vasoconstriction syndrome is a disease characterized by a weeks-long course of thunderclap headaches, sometimes focal neurologic signs, and occasionally seizures. Symptoms are thought to arise from transient abnormalities in the blood vessels of the brain. In some cases, it may be associated with childbirth, vasoactive or illicit drug use, or complications of pregnancy. If it occurs after delivery it may be referred to as postpartum cerebral angiopathy.

Pediatric stroke

Pediatric stroke is a stroke that happens in children or adolescents. Stroke affects about 6 in 100,000 children. Stroke is a leading cause of death in children in the U.S.

References

  1. 1 2 3 4 5 6 7 8 9 10 Schwedt TJ, Matharu MS, Dodick DW (July 2006). "Thunderclap headache". Lancet Neurol. 5 (7): 621–31. doi:10.1016/S1474-4422(06)70497-5. PMID   16781992.
  2. 1 2 Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW (October 2008). "Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache". Ann Emerg Med. 52 (4): 407–36. doi:10.1016/j.annemergmed.2008.07.001. PMID   18809105.
  3. 1 2 3 4 Devenney, Emma; Neale, Hazel; Forbes, Raeburn B (14 August 2014). "A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based?". The Journal of Headache and Pain. 15 (1). doi:10.1186/1129-2377-15-49. PMC   4231167 . PMID   25123846.
  4. Dilli, Esma (April 2014). "Thunderclap headache". Current Neurology and Neuroscience Reports. 14 (4): 437. doi:10.1007/s11910-014-0437-9. PMID   24643327.
  5. Symonds CP (1924). "Spontaneous subarachnoid hemorrhage". Quarterly Journal of Medicine. 18: 93–122. doi:10.1093/qjmed/os-118.69.93.
  6. Longstreth WT, Koepsell TD, Yerby MS, van Belle G (1985). "Risk factors for subarachnoid hemorrhage" (PDF). Stroke. 16 (3): 377–85. doi:10.1161/01.STR.16.3.377. PMID   3890278.
  7. Day JW, Raskin NH (November 1986). "Thunderclap headache: symptom of unruptured cerebral aneurysm". Lancet. 2 (8518): 1247–8. doi:10.1016/S0140-6736(86)92677-2. PMID   2878133.

Further reading

Classification
D