Editing Thunderclap headache

{{short description|Severe and sudden-onset headache}}
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| name            = Thunderclap headache
| synonyms        = Lone acute severe headache
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A '''thunderclap headache''' is a [[headache]] that is severe and has a  sudden onset. It is defined as a severe headache that takes seconds to minutes to reach maximum intensity.<ref name=Schwedt>{{cite journal |vauthors=Schwedt TJ, Matharu MS, Dodick DW |title=Thunderclap headache |journal=Lancet Neurol |volume=5 |issue=7 |pages=621–31 |date=July 2006 |pmid=16781992 |doi=10.1016/S1474-4422(06)70497-5|s2cid=5511658 }}</ref><ref name=ACEP2008>{{cite journal |vauthors=Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW |title=Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache |journal=Ann Emerg Med |volume=52 |issue=4 |pages=407–36 |date=October 2008 |pmid=18809105 |doi=10.1016/j.annemergmed.2008.07.001 |s2cid=507361 | url=http://www.annemergmed.com/article/S0196-0644(08)01463-7/fulltext|url-access=subscription }}</ref> Although approximately 75% are attributed to "primary" headaches—headache disorder, non-specific headache, idiopathic thunderclap headache, or uncertain headache disorder—the remainder are secondary to other causes, which can include some extremely dangerous acute conditions, as well as infections and other conditions.<ref name=Devenney>{{cite journal|last1=Devenney|first1=Emma|last2=Neale|first2=Hazel|last3=Forbes|first3=Raeburn B|title=A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based?|journal=[[The Journal of Headache and Pain]]|date=14 August 2014|volume=15|issue=1|page=49|doi=10.1186/1129-2377-15-49|pmid=25123846|pmc=4231167 |doi-access=free }}</ref> Usually, further investigations are performed to identify the underlying cause.<ref name=Schwedt/>

==Signs and symptoms==
A headache is called "thunderclap headache" if it is severe in character and reaches maximum severity within seconds to minutes of onset. In many cases, there are no other abnormalities, but the various causes of thunderclap headaches may lead to a number of neurological symptoms.{{cn|date=August 2021}}

==Causes==
Approximately 75% are attributed to "primary" headaches: headache disorder, non-specific headache, idiopathic thunderclap headache or uncertain headache disorder.<ref name=Devenney/>  The remainder are secondary to a number of conditions, including:<ref name=Schwedt/><ref name=Devenney/>
* [[Subarachnoid hemorrhage]] (10–25% of all cases of thunderclap headache)
* [[Cerebral venous sinus thrombosis]]
* [[Cervical artery dissection]]
* [[Hypertensive emergency]] (severely raised blood pressure)
* [[Spontaneous intracranial hypotension]] (unexplained low [[cerebrospinal fluid]] pressure)
* [[Stroke]] (headache occurs in about 25% of strokes but usually not thunderclap character)
* [[Retroclival hematoma]] (hematoma behind the [[clivus (anatomy)|clivus]] in the skull, usually due to physical trauma but sometimes spontaneous)
* [[Pituitary apoplexy]] (infarction or hemorrhage of the [[pituitary gland]])
* [[Colloid cyst]] of the [[third ventricle]]
* [[Meningitis]], sinusitis
* [[Reversible cerebral vasoconstriction syndrome]] (previously Call-Fleming syndrome, several subtypes)
* Primary cough headache, primary exertional headache, and primary [[sexual headache]]

The most important of the secondary causes are [[subarachnoid hemorrhage]], [[cerebral venous sinus thrombosis]], and [[Dissection (medical)|dissection]] of an artery in the neck.<ref name=Schwedt/><ref>{{Cite journal|last=Dilli|first=Esma|date=April 2014|title=Thunderclap headache|journal=Current Neurology and Neuroscience Reports|volume=14|issue=4|pages=437|doi=10.1007/s11910-014-0437-9|pmid=24643327|s2cid=37813850}}</ref>

In [[subarachnoid hemorrhage]], there may be [[syncope (medicine)|syncope]] (transient loss of consciousness), [[Convulsions|seizures]], [[meningism]] (neck pain and stiffness), visual symptoms, and [[vomiting]]. 50–70% of people with subarachnoid hemorrhage have an isolated headache without [[decreased level of consciousness]]. The headache typically persists for several days.<ref name=Schwedt/>

[[Cerebral venous sinus thrombosis]], thrombosis of the veins of the brain, usually causes a headache that reflects raised [[intracranial pressure]] and is therefore made worse by anything that makes the pressure rise further, such as [[cough]]ing. In 2–10% of cases, the headache is of thunderclap character. In most cases there are other neurological abnormalities, such as seizures and weakness of part of the body, but in 15–30% the headache is the only abnormality.<ref name=Schwedt/>

[[Carotid artery dissection]] and [[vertebral artery dissection]] (together cervical artery dissection), in which a tear forms inside the wall of the blood vessels that supply the brain, often causes pain on the affected side of the head or neck. The pain usually precedes other problems that are caused by impaired blood flow through the artery into the brain; these may include visual symptoms, weakness of part of the body, and other abnormalities depending on the vessel affected.<ref name=Schwedt/>

==Diagnosis==
The most important initial investigation is [[computed tomography]] of the brain, which is very sensitive for subarachnoid hemorrhage. If this is normal, a [[lumbar puncture]] is performed, as a small proportion of SAH is missed on CT and can still be detected as [[xanthochromia]].<ref name=Schwedt/><ref name=ACEP2008/>

If both investigations are normal, the specific description of the headache and the presence of other abnormalities may prompt further tests, usually involving [[magnetic resonance imaging]] (MRI). [[Magnetic resonance angiography]] (MRA) may be useful in identifying problems with the arteries (such as dissection), and magnetic resonance venography (MRV) identifies venous thrombosis. It is not usually necessary to proceed to [[cerebral angiography]], a more precise but invasive investigation of the brain's blood vessels, if MRA and MRV are normal.<ref name=Schwedt/>

==Epidemiology==
Incidence of thunderclap headache has been estimated at 43 per 100,000 people every year. Approximately 75% are attributed to "primary" headaches: headache disorder, non-specific headache, idiopathic thunderclap headache or uncertain headache disorder. The remainder is attributed to secondary causes: vascular problems, infections and various other conditions.<ref name=Devenney/>

==History==
The importance of severe headaches in the diagnosis of subarachnoid hemorrhage has been known since the 1920s, when London neurologist [[Charles Symonds]] described the clinical syndrome.<ref>{{cite journal | author=Symonds CP | title=Spontaneous subarachnoid hemorrhage | journal=Quarterly Journal of Medicine | year=1924 | volume=18 | issue=69 | pages=93–122 | doi=10.1093/qjmed/os-118.69.93 }}</ref><ref name=Longstreth>{{cite journal |vauthors=Longstreth WT, Koepsell TD, Yerby MS, van Belle G |title=Risk factors for subarachnoid hemorrhage |journal=Stroke |volume=16 |issue=3 |pages=377–85 |year=1985 |pmid=3890278 |url=http://stroke.ahajournals.org/cgi/reprint/16/3/377.pdf|doi=10.1161/01.STR.16.3.377|doi-access=free }}</ref> The term "thunderclap headache" was introduced in 1986 in a report by John Day and Neil Raskin, neurologists at the [[University of California, San Francisco]], in a report of a 42-year-old woman who had experienced several sudden headaches and was found to have an aneurysm that had not ruptured.<ref name=Schwedt/><ref>{{cite journal |vauthors=Day JW, Raskin NH |title=Thunderclap headache: symptom of unruptured cerebral aneurysm |journal=Lancet |volume=2 |issue=8518 |pages=1247–8 |date=November 1986 |pmid=2878133 |doi=10.1016/S0140-6736(86)92677-2|s2cid=7289947 }}</ref>

==References==
{{Reflist}}

==Further reading==
* {{cite journal|last=Dodick|first=DW|title=Thunderclap headache|journal=Journal of Neurology, Neurosurgery & Psychiatry|date=1 January 2002|volume=72|issue=1|pages=6–11|doi=10.1136/jnnp.72.1.6|pmc=1737692|pmid=11784817}}
* {{cite journal|last=Ju|first=Yo-El|author2=Schwedt, Todd |title=Abrupt-Onset Severe Headaches|journal=Seminars in Neurology|date=29 March 2010|volume=30|issue=2|pages=192–200|doi=10.1055/s-0030-1249229|pmid=20352589|pmc=3558726}}
* {{cite journal|last=Ducros|first=A|author2=Bousser, MG |title=Thunderclap headache|journal=BMJ|date=9 January 2013|volume=346|issue=jan08 15|pages=e8557|doi=10.1136/bmj.e8557|pmid=23303883|s2cid=2537784}}

== External links ==
{{Medical resources
|  DiseasesDB     = 33023
|  ICD10          = {{ICD10|G|44|8}}
|  ICD9           = {{ICD9|339.43}}
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{{Headache}}

[[Category:Headaches]]