Thunderclap headache

Jonathan H. Smith, Todd J Schwedt

Research output: Chapter in Book/Report/Conference proceedingChapter


In a patient presenting with severe headache, differentiating an idiopathic primary headache from a symptomatic secondary headache is the first task of the provider. The failure to recognize a secondary cause for the severe headache can result in significant increases in morbidity and mortality. The term thunderclap headache (TCH) refers to a sudden onset of intense and explosive headache, a phenotype recognized to be associated with multiple pathologies including aneurysmal subarachnoid hemorrhage. This chapter gives a critical review of the evidence by discussing the risks of secondary TCH and the differential diagnosis of TCH. The methods of diagnosis involving lumbar puncture (LP), advanced noninvasive neuroimaging and invasive angiography are discussed with reference to their necessity in diagnosing TCH. In individuals with delayed or atypical presentations and in those with negative CT and LP, brain MRI and noninvasive angiography should be considered. The prevalent nature of incidental unruptured intracranial aneurysms is an important factor often cited as reason to avoid advanced vascular imaging. Objective biomarkers and risk stratification tools are needed to better assess an unruptured intracranial aneurysm discovered in the evaluation of TCH. Future studies should also specifically assess the risk of CAD, CVST, RCVS and others among patients presenting with TCH, and explore the costs against potential benefits of routinely screening for these conditions.

Original languageEnglish (US)
Title of host publicationEvidence-Based Neurology
Subtitle of host publicationManagement of Neurological Disorders: Second Edition
PublisherWiley Blackwell
Number of pages12
ISBN (Electronic)9781119067344
ISBN (Print)9780470657782
StatePublished - Dec 11 2015


  • Cerebral venous sinus thrombosis
  • Primary TCH
  • Reversible cerebral vasoconstriction syndrome
  • Secondary TCH
  • Subarachnoid hemorrhage
  • Thunderclap headache

ASJC Scopus subject areas

  • Medicine(all)


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