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thunderclap headache

Etiology: - primary headaches - primary stabbing headache 'ice-pick' headache - primary cough headache - primary exertional headache - primary sexual headache - primary thunderclap headache [1] - secondary headaches - vascular disorder identified in 30-80% of patients - subarachnoid hemorrhage (25%) - most common cause - intraparenchymal hemorrhagic stroke - cerebral arterial thrombosis (ischemic stroke) * - transient ischemic attack* - cerebral venous thrombosis - dural sinus thrombosis - arterial dissection - carotid artery dissection - vertebral artery dissection - basilar artery dissection - sentinel bleeding from unruptured intracranial aneurysm - reversible cerebral vasoconstriction syndrome* [1] (2nd most common cause) - pituitary apoplexy - spontaneous intracranial hypotension - posterior reversible encephalopathy syndrome - colloid cyst occlusion of the 3rd ventricle [1] - idiopathic * ischemic stroke & TIA are generally painless Pathology: - 85% of thunderclap headaches due to subarachnoid hemorrhage result from previously unidentified cerebral aneurysms [1] Clinical manifestations: - severe, explosive headache at maximal intensity within 60 seconds of onset [1] - case presentation of abrupt-onset severe headache lasting 6-8 hours [1] - may occur in isolation or may be recurrent over days to weeks - may begin spontaneously - may be triggered by a) Valsalva maneuver b) physical exertion, including sexual intercourse c) shower [1] Special laboratory: - lumbar puncture (after head CT) - CSF analysis - no evidence of subarachnoid hemorrhage Radiology: - non-contrast CT of the head (emergency) - magnetic resonance imaging (MRI) angiography - CT angiography Management: - normalization of blood pressure [1] - calcium channel blocker 1st line for thunderclap headache due to reversible cerebral vasoconstriction syndrome - nimodipine, verapamil [1] - indomethacin may be appropriate after intracranial hemorrhage or impending intracranial hemorrhage has been ruled out [1]

Specific

reversible cerebral vasoconstriction syndrome (Call-Fleming syndrome)

General

headache

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15,16,17,18,19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Schwedt TJ et al Thunderclap headache. Lancet Neurol. 2006 Jul;5(7):621-31. PMID: 16781992