Thunderclap headache, a severe and explosive headache with a maximum intensity occurring within a minute of symptom onset, may have a more serious underlying pathology.
HONOLULU—A first-ever episode of thunderclap headache may be a symptomatic headache of an underlying disorder, according to research presented at the 63rd Annual Meeting of the American Academy of Neurology.
“Primary thunderclap headache can last from one hour to 10 days, and a diagnosis can be made only after the exclusion of another disorder,” reported David Dolezil, PhD, Head of the Department of Neurology at Charles University in Prague, and colleagues. “First-ever thunderclap headache has to be considered as a symptomatic headache [related to another disorder] such as subarachnoid hemorrhage, cerebral venous sinus thrombosis, cerebral artery dissection, reversible cerebral vasoconstriction syndrome, meningitis, or other primary headache such as cough, exertional, or sexual headache.”
The researchers conducted a six-month prospective study of 21 patients (11 women; mean age, 52) who presented with possible thunderclap headache at a neurology clinic. “The first step of the diagnosis procedure was to obtain a history of present and previous headaches, other relevant medical history, and concomitant medication, as well as neurologic and physical examination,” Dr. Dolezil stated.
All patients with thunderclap headache syndrome underwent brain CT immediately, according to Dr. Dolezil, as did some patients with suspicion of ischemic stroke, subarachnoid hemorrhage, cerebral venous sinus thrombosis, and/or cerebral artery dissection.
If the results of the head CT were normal, patients underwent lumbar puncture procedure for CSF analysis to exclude infectious disorders and subarachnoid hemorrhage. Patients who had negative results on all examinations underwent MRI and magnetic resonance angiography five to 10 days after the onset of sudden headache.
The researchers monitored and recorded the patients’ pain intensity; the location, duration, and quality of headache; onset time; related symptoms such as nausea, vomiting, photophobia, and phonophobia; and autonomic signs and neurologic findings.
Among the 21 patients included with clinical signs of thunderclap headache, “the mean score of pain intensity on a pain scale of 0 to 10 was 8.4, and the mean time of duration of headache was 131 hours,” noted the investigators.
Eight patients (five women) in one subgroup (mean age, 33) had a diagnosis of primary headache—two patients had thunderclap headache, three had orgasmic headache, one had exertional headache, and two had a first attack of migraine with aura. Thirteen patients (six women) from a second subgroup (mean age, 63) had a secondary headache—five patients had ischemic stroke, one had hemorrhagic stroke, two had subarachnoid hemorrhage, one had meningitis, one had atypical subdural hematoma, one had posterior reversible encephalopathy syndrome, one had psychosis, and one had lymphadenitis of the neck, according to the researchers.