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Home > Headache Education > NHF HeadLines Excerpts > Case Studies in Headache Archive > Case Studies in Headache Issue #166 - January/February 2009
Case Study—Thunderclap Headache
By Todd Schwedt, MD, Director of the Washington University Headache Center in St. Louis, Missouri
A 52-year-old woman was sitting on her sofa watching television when she had a rapid onset of excruciatingly severe pain located in the back of her head and upper neck. Although she had gotten a few headaches over the years, this headache frightened her due to the quickness with which it started and its extreme intensity. She described it as “like getting hit in the back of the head with a bat.” Since she was sure that something ominous had occurred, she called 911.
DISCUSSION
This woman has experienced a “thunderclap headache,” so named because of its rapid onset and extremely high level of severity, which is likened to being hit with a “clap of thunder.” By definition, thunderclap headaches reach maximum intensity within a few seconds to one minute. These features make it possible to differentiate thunderclap headaches from more common headache types like tension-type headache and migraine. Although migraine headaches can become quite severe, they generally reach their peak severity over tens of minutes to hours.
The pain of a thunderclap headache may occur by itself or there may be other symptoms, including nausea, vomiting, visual changes, weakness, numbness and changes in level of awareness. Thunderclap headaches may come on spontaneously, with no identifiable trigger. Alternatively, a thunderclap headache may be preceded by physical exertion, straining, ingestion of certain medications or illicit drugs, or following exposure to warm water, such as when the body is immersed in a warm bath or when water from a hot shower hits the body. Thunderclap headaches are medical emergencies that require immediate evaluation.
Although there are many possible causes of a thunderclap headache, the foremost concern is bleeding around the brain, a condition called subarachnoid hemorrhage. This type of bleeding is most often caused by rupture of a weak area in the wall of an artery (aneurysm rupture). Since this condition may be associated with significant disability and even death, a person experiencing a thunderclap headache needs to seek medical attention immediately. Other possible causes of this headache include unruptured aneurysms, tearing or narrowing of arteries in the head or neck, blockage of veins in the head, brain infections, leakage of spinal fluid, and several others.
In a substantial proportion of people with thunderclap headaches no cause for the pain is determined. They are considered to have primary thunderclap headache. However, it should never be assumed that a person has a primary thunderclap headache until a comprehensive diagnostic evaluation rules out potential causes.
Although the evaluation of a patient with thunderclap headache may differ from case to case, imaging of the brain with a CT scan and evaluation of the spinal fluid via a spinal tap is generally required. These tests help the healthcare provider to determine if there has been bleeding around the brain and provide useful information that may help diagnose other causes for the thunderclap headache. Depending upon the results of the CT scan and spinal tap, other necessary tests may include MRI of the brain and imaging of the blood vessels in the head and neck.
Treatment of a thunderclap headache focuses on pain relief and treatment of the underlying cause, if found. Since there are multiple possible causes, treatment varies widely from case to case.
CASE CONCLUSION
The 52-year-old woman with thunderclap headache was taken to her local emergency room for evaluation. The physical examination, brain and blood vessel imaging, and spinal tap were normal. She was diagnosed with primary thunderclap headache and was admitted to the hospital for pain control. Her headache resolved overnight. She was put on verapamil (a calcium-channel blocker and blood pressure medication) for prevention of headache recurrence and discharged the next day.
Case Studies in Headache Archive #166 - January/February 2009
Case Study—Thunderclap Headache
By Todd Schwedt, MD, Director of the Washington University Headache Center in St. Louis, Missouri
A 52-year-old woman was sitting on her sofa watching television when she had a rapid onset of excruciatingly severe pain located in the back of her head and upper neck. Although she had gotten a few headaches over the years, this headache frightened her due to the quickness with which it started and its extreme intensity. She described it as “like getting hit in the back of the head with a bat.” Since she was sure that something ominous had occurred, she called 911.
DISCUSSION
This woman has experienced a “thunderclap headache,” so named because of its rapid onset and extremely high level of severity, which is likened to being hit with a “clap of thunder.” By definition, thunderclap headaches reach maximum intensity within a few seconds to one minute. These features make it possible to differentiate thunderclap headaches from more common headache types like tension-type headache and migraine. Although migraine headaches can become quite severe, they generally reach their peak severity over tens of minutes to hours.
The pain of a thunderclap headache may occur by itself or there may be other symptoms, including nausea, vomiting, visual changes, weakness, numbness and changes in level of awareness. Thunderclap headaches may come on spontaneously, with no identifiable trigger. Alternatively, a thunderclap headache may be preceded by physical exertion, straining, ingestion of certain medications or illicit drugs, or following exposure to warm water, such as when the body is immersed in a warm bath or when water from a hot shower hits the body. Thunderclap headaches are medical emergencies that require immediate evaluation.
Although there are many possible causes of a thunderclap headache, the foremost concern is bleeding around the brain, a condition called subarachnoid hemorrhage. This type of bleeding is most often caused by rupture of a weak area in the wall of an artery (aneurysm rupture). Since this condition may be associated with significant disability and even death, a person experiencing a thunderclap headache needs to seek medical attention immediately. Other possible causes of this headache include unruptured aneurysms, tearing or narrowing of arteries in the head or neck, blockage of veins in the head, brain infections, leakage of spinal fluid, and several others.
In a substantial proportion of people with thunderclap headaches no cause for the pain is determined. They are considered to have primary thunderclap headache. However, it should never be assumed that a person has a primary thunderclap headache until a comprehensive diagnostic evaluation rules out potential causes.
Although the evaluation of a patient with thunderclap headache may differ from case to case, imaging of the brain with a CT scan and evaluation of the spinal fluid via a spinal tap is generally required. These tests help the healthcare provider to determine if there has been bleeding around the brain and provide useful information that may help diagnose other causes for the thunderclap headache. Depending upon the results of the CT scan and spinal tap, other necessary tests may include MRI of the brain and imaging of the blood vessels in the head and neck.
Treatment of a thunderclap headache focuses on pain relief and treatment of the underlying cause, if found. Since there are multiple possible causes, treatment varies widely from case to case.
CASE CONCLUSION
The 52-year-old woman with thunderclap headache was taken to her local emergency room for evaluation. The physical examination, brain and blood vessel imaging, and spinal tap were normal. She was diagnosed with primary thunderclap headache and was admitted to the hospital for pain control. Her headache resolved overnight. She was put on verapamil (a calcium-channel blocker and blood pressure medication) for prevention of headache recurrence and discharged the next day.