Primary Thunderclap Headache





Key words

computerized tomography, lone acute severe headache, lumbar puncture, pneumopcephalus, subarachnoid hemorrhage, thunderclap headache

 





ICD-10 CODE G44.53





The Clinical Syndrome


Thunderclap headache, which is also known as lone acute severe headache, is an uncommon type of headache that may be the result of an underlying vascular or nonvascular intracranial abnormality or may represent a primary headache syndrome of unknown cause. Common and uncommon causes of thunderclap headache are listed in Table 9.1 . The more benign, though no less painful, primary thunderclap headache occurs over three times more frequently than the serious secondary thunderclap headache. Because of the often-threatening causes of the less common secondary thunderclap headache (e.g., subarachnoid hemorrhage, cerebral venous thrombosis), urgent evaluation including computed tomography (CT) and/or magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid analysis are indicated in all patients suspected of having thunderclap headache.



TABLE 9.1

Main and Rare Causes of Thunderclap Headache






















































Main Causes Rare Causes
Vascular Disorders
Subarachnoid hemorrhage Pituitary apoplexy, arteritis, angiitis
Intracerebral hemorrhage Unruptured vascular malformation, aneurysm
Cerebral venous thrombosis Arterial hypertension
Spontaneous intracranial hypotension Cerebral segmental vasoconstriction
Cervical artery dissection
Nonvascular Disorders
Greater occipital neuralgia
Intermittent hydrocephalus by colloid cyst
Infections
Meningitis, encephalitis Erve virus
Sinusitis
Primary Headache Disorders
Migraine Cluster headache
Primary thunderclap headache Tension headache, new daily persistent headache
Primary exertional headache
Primary cough headache

Modified from Linn FHH. Primary thunderclap headache. In: Aminoff MJ, ed. Handbook of Clinical Neurology. Vol. 97. New York: Elsevier; 2010:473–481.


One of the most severe headaches encountered in clinical practice, thunderclap headache is characterized by a very rapid onset to peak of less than 1 minute. The headache may last from 1 to 10 days and, because of its intensity, almost always provokes an urgent trip to the emergency department, where the headache is invariably initially misdiagnosed as the sentinel headache of acute subarachnoid hemorrhage or other potentially catastrophic headache syndromes ( Tables 9.2 and 9.3 ). This is not surprising in that primary thunderclap headache is virtually indistinguishable clinically from subarachnoid hemorrhage, one of the most neurologically devastating forms of cerebrovascular accident. Thus, because of the serious consequences of misdiagnosis, by necessity primary thunderclap headache is a diagnosis of exclusion.



TABLE 9.2

Comparison of Primary Thunderclap Headache and Subarachnoid Hemorrhage




































Comparison Factors Primary Thunderclap Headache Subarachnoid Hemorrhage
Severe headache Yes Yes
Nausea and vomiting Yes Yes
Focal neurological signs No Yes
Nuchal rigidity No Yes
Photophobia No Yes
Vertigo No Yes
Neck and back pain No Yes


TABLE 9.3

Diseases That May Mimic Primary Thunderclap Headache




















































  • Hemorrhagic




  • Ischemic




  • Neoplasm




  • Infection




  • Meningitis




  • Encephalitis




  • Abscess




  • Parasitic




  • Hypertensive crisis




  • Loss of spinal fluid




  • Postdural puncture headache




  • Spontaneous spinal fluid leak




  • Collagen-vascular disease




  • Lupus cerebritis




  • Vasculitis




  • Polymyositis




  • Headache




  • Cluster headache




  • Primary exertional headache




  • Primary cough headache




  • Migraine




  • Ice pick headache




  • Primary sexual headache

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Feb 9, 2020 | Posted by in PAIN MEDICINE | Comments Off on Primary Thunderclap Headache

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