Thunderclap headache: an update

ABSTRACT

Introduction: Thunderclap headache (TCH) is an excruciating headache that reaches maximal intensity within a minute. It has numerous potential etiologies, the most concerning of which is subarachnoid hemorrhage (SAH) due to high morbidity and mortality. Thus, patients with TCH must be evaluated urgently to identify the underlying cause and initiate prompt therapy.

Areas covered: This paper reviews PubMed-listed research articles and presents an update of the clinical features, diagnostic evaluation, and possible causes of TCH.

Expert commentary: In addition to SAH, TCH has been associated with reversible cerebral vasoconstriction syndrome (RCVS), cervical artery dissection, cerebral venous sinus thrombosis, cerebral infarction, intracerebral hemorrhage, spontaneous intracranial hypotension, intracranial infection, and pituitary apoplexy. Of note, with advances in knowledge in the past decade, RCVS has become an important cause of TCH, being diagnosed more frequently. Brain computed tomography (CT) should be performed in all patients with TCH, and lumbar puncture is indicated if the brain CT is nondiagnostic. Generally, a negative brain CT and lumbar puncture can eliminate SAH diagnosis, in which case brain magnetic resonance imaging and vascular imaging should be performed to evaluate other possible underlying causes.

KEYWORDS:

• Thunderclap headache
• subarachnoid hemorrhage
• reversible cerebral vasoconstriction syndrome

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The manuscript was supported by grants from Taipei Veterans General Hospital (V107C-032) and Brain Research Center, National Yang-Ming University from The Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan.