{ "schemaVersion": 2, "eyebrow": "Emergency Neurology", "title": "Thunderclap Headache", "summary": "Thunderclap headache requires urgent exclusion of subarachnoid hemorrhage and targeted evaluation for vascular, hemorrhagic, venous, pituitary, and pressure-related disorders. Recurrent attacks, triggers, examination, cerebrospinal fluid, and vascular imaging direct evaluation toward reversible cerebral vasoconstriction syndrome or competing secondary causes.", "seoDescription": "Physician approach to thunderclap headache: exclude subarachnoid hemorrhage, select CT, lumbar puncture and vascular imaging, and identify RCVS and mimics.", "clinicalQuestion": "How should physicians rapidly evaluate thunderclap headache while distinguishing subarachnoid hemorrhage, RCVS, and other dangerous secondary causes?", "specialty": "Emergency Medicine and Neurology", "audience": "U.S. physicians and medical trainees", "tags": [ "thunderclap headache", "subarachnoid hemorrhage", "reversible cerebral vasoconstriction syndrome", "RCVS", "cerebral venous thrombosis", "cervical artery dissection", "lumbar puncture" ], "keyTakeaways": [ "A headache reaching maximal intensity within 60 seconds is thunderclap headache and warrants urgent evaluation for secondary causes even in patients with an established primary headache disorder. [1][14]", "Use noncontrast head CT as the first examination; if CT is normal and concern for subarachnoid hemorrhage remains, proceed to lumbar puncture. [1][5][17]", "Recurrent thunderclap attacks over days to 1–3 weeks, particularly with bathing, exertion, sexual activity, coughing, positional change, or vasoactive exposure, should prompt evaluation for RCVS. [6][11][16]", "Normal CT and cerebrospinal fluid do not exclude RCVS, cervical artery dissection, cerebral venous thrombosis, or pituitary apoplexy; select CTA/MRA of cerebral and cervical vessels and brain MRI/MRV according to the clinical pattern. [1][17][24]", "RCVS requires multifocal constriction in at least two cerebral arteries and documented resolution by 3 months after excluding aneurysmal subarachnoid hemorrhage and primary angiitis of the CNS. [6]" ], "sections": [ { "id": "initial-emergency-assessment", "eyebrow": "First Encounter", "heading": "Treat Thunderclap Headache as a Secondary Headache Until Proven Otherwise", "intro": "The time-to-peak history determines the emergency pathway.", "paragraphs": [ "Classify the presentation as thunderclap headache when severe pain reaches maximum intensity within 60 seconds. Do not attribute this phenotype to migraine, sexual headache, or a prior recurrent headache disorder before evaluating secondary causes; aneurysmal subarachnoid hemorrhage (SAH) is the most common cause, but cervical artery dissection, cerebral venous thrombosis (CVT), intracerebral hemorrhage, ischemic stroke, pituitary apoplexy, intracranial infection, spontaneous intracranial hypotension, acute hypertensive crisis, and third-ventricle colloid cyst are established alternatives. [1][14][15]", "Perform focused neurologic and ocular examination, assess mental status, and identify seizure, meningismus, cranial neuropathy, focal deficit, or visual symptoms. A normal examination does not safely narrow the differential: cervical artery dissection, CVT, RCVS, and pituitary apoplexy can present with isolated thunderclap headache despite normal examination, CT, and cerebrospinal fluid (CSF) findings. [1]", "Obtain noncontrast head CT immediately as the initial study to detect SAH, intraparenchymal hemorrhage, and major ischemic injury. CT also identifies some alternative emergencies, but early CT may be normal in conditions such as cerebellar infarction, for which diffusion-weighted MRI is more sensitive. [17][22]" ], "bullets": [ "Ask specifically about a single persistent explosive headache versus recurrent discrete attacks; recurrence over days favors RCVS, whereas one severe event remains concerning for aneurysmal SAH and other structural emergencies. [10][16]", "Elicit postpartum status; recent exposure to cannabis, cocaine, binge alcohol, serotonergic or noradrenergic antidepressants, triptans, ergots, nasal decongestants, nicotine replacement, epinephrine, interferon alfa, cyclosporine, steroids, or sulprostone; and recent surgical or vascular manipulation. These exposures are recognized RCVS precipitants. [6]", "Ask about exertion, showering or bathing, sexual activity, cough, stress, and positional change, which commonly trigger recurrent RCVS attacks. [16]" ], "subsections": [], "table": { "caption": "Immediate diagnostic priorities for thunderclap headache. [1][17][24]", "columns": [ "Presentation feature", "Priority diagnosis", "Next diagnostic action" ], "rows": [ [ "Any thunderclap headache", "SAH or other intracranial hemorrhage", "Noncontrast head CT first. [1][17]" ], [ "Normal CT with unresolved concern for SAH", "CT-occult SAH", "Lumbar puncture. [1][5]" ], [ "Recurrent attacks over days, vasoactive exposure, postpartum state, or exertional/sexual/bathing trigger", "RCVS", "CTA or MRA of intracranial vessels; repeat vascular assessment may be needed when early imaging is unrevealing. [6][16][20][24]" ], [ "Postpartum state or cortical sulcal SAH", "CVT or cortical vein thrombosis", "Brain MRI with susceptibility sequences and MR venography. [17]" ], [ "Neck pain or suspicion for vascular injury", "Cervical artery dissection", "Cervical and cerebral vascular imaging with CTA or MRA. [1][24]" ] ] } }, { "id": "exclude-subarachnoid-hemorrhage", "eyebrow": "Hemorrhage Pathway", "heading": "Use CT and Lumbar Puncture to Exclude Subarachnoid Hemorrhage", "intro": "SAH exclusion precedes a diagnosis of primary thunderclap headache or uncomplicated RCVS.", "paragraphs": [ "After a negative noncontrast CT, perform lumbar puncture when SAH remains a diagnostic concern. This CT-then-CSF sequence is the standard evaluation emphasized for thunderclap headache because a normal CT alone does not resolve concern for CT-occult hemorrhage. [1][5]", "A normal examination, CT, and CSF analysis make subsequent SAH very unlikely in longitudinal case series and do not mandate angiography solely to exclude SAH. However, this does not end evaluation when the phenotype or risk profile suggests another vascular disorder. [8][1]", "Use CTA or MRA selectively after normal CT and CSF when there are equivocal prior findings, subtle cranial nerve abnormalities, or a compelling reason to assess for aneurysm, including personal or family history of aneurysm or SAH, connective-tissue disorder, or polycystic kidney disease. CTA/MRA are reported to be more than 90% sensitive for aneurysms larger than 5 mm; catheter angiography carries an approximately 1% risk of symptomatic cerebral ischemia. [7]", "Interpret an unruptured aneurysm found after a negative CT/LP cautiously. Aneurysms may be incidental, and large prospective cohorts report an approximately 0.1% annual SAH rate for aneurysms under 7 mm; correlation with the headache syndrome and imaging findings is necessary before assigning causality. [7][8]" ], "bullets": [ "If CT demonstrates subarachnoid blood, pursue vascular evaluation for aneurysmal and nonaneurysmal hemorrhage rather than labeling the patient as RCVS based on vasoconstriction alone. [6][23]", "If CT and CSF are normal but thunderclap attacks recur or focal symptoms emerge, continue etiologic evaluation with cerebral/cervical vascular imaging and MRI rather than diagnosing primary thunderclap headache. [1][16][20]" ], "subsections": [], "table": { "caption": "How negative hemorrhage testing changes, but does not end, the thunderclap headache workup. [1][7][8]", "columns": [ "Result", "Interpretation", "Decision" ], "rows": [ [ "CT shows intracranial hemorrhage", "Hemorrhage is established; determine the cause. [17][23]", "Obtain vascular and etiologic imaging directed by hemorrhage pattern. [23]" ], [ "CT normal; CSF not yet assessed despite ongoing SAH concern", "SAH remains insufficiently excluded. [1][5]", "Perform lumbar puncture. [1][5]" ], [ "Normal examination, CT, and CSF", "Subsequent SAH is very unlikely. [8]", "Do not perform angiography solely to exclude SAH; investigate specific alternate diagnoses when indicated. [1][8]" ], [ "Normal CT/CSF with high-risk aneurysm context or equivocal findings", "Aneurysm assessment may still change management. [7]", "Use CTA or MRA; reserve catheter angiography for selected circumstances given procedural ischemic risk. [7]" ] ] } }, { "id": "rcvs-recognition-and-confirmation", "eyebrow": "Vasoconstriction Pathway", "heading": "Recognize and Confirm Reversible Cerebral Vasoconstriction Syndrome", "intro": "The hallmark is recurrent thunderclap headache with reversible multifocal arterial narrowing.", "paragraphs": [ "Suspect RCVS when thunderclap headaches recur in a waxing-and-waning pattern for 1–3 weeks, often resolving within 3 hours before another severe attack occurs. The final severe episode occurs at a mean of 7–8 days after onset, and patients may have a lower-grade headache between attacks. [16]", "Confirm RCVS with cerebral vascular imaging showing segmental, multifocal vasoconstriction involving at least two arteries, then demonstrate resolution within 3 months. CTA and MRA are reliable noninvasive modalities; digital subtraction angiography is the reference standard when noninvasive studies are nondiagnostic and clinical suspicion remains high. [6][24]", "Do not exclude RCVS after an initially normal angiogram in a patient with a typical recurrent thunderclap phenotype. Vasoconstriction may be absent on initial noninvasive studies, while angiographic vasoconstriction reaches maximum severity about 2–3 weeks after clinical onset; repeat vascular imaging or digital subtraction angiography and close follow-up are reasonable when suspicion remains high. [10][20]", "Exclude aneurysmal SAH and assess for primary angiitis of the CNS (PACNS) before finalizing RCVS. Parenchymal CT or MRI abnormalities were reported in all PACNS patients versus 31% of RCVS patients in one comparison, but this imaging distinction is supportive rather than independently diagnostic. [6]" ], "bullets": [ "Potential RCVS complications include ischemic stroke, intracerebral hemorrhage, convexity or nonaneurysmal SAH, and posterior reversible encephalopathy syndrome. [3][11][17]", "Perform brain CT or MRI to evaluate complications; use MRI when CT is unrevealing and symptoms, deficits, seizure, or subsequent attacks raise concern for infarction or other parenchymal injury. [17][22]", "Consider transcranial Doppler for monitoring cerebral vasoconstriction. Middle cerebral artery mean flow velocity may be normal early and peak around 3 weeks; a velocity greater than 120 m/s was associated with increased ischemic-complication risk in one study. [11][13]" ], "subsections": [ { "heading": "Initial management when RCVS is suspected", "paragraphs": [ "Immediately discontinue or avoid identifiable vasoactive precipitants where feasible, including recreational sympathomimetic or serotonergic exposures and implicated prescription agents. This is the principal cause-directed intervention while serial clinical and imaging assessment defines the course. [6][24]", "Nimodipine may reduce thunderclap headache frequency or severity within 48 hours, but it has no proven effect on hemorrhagic or ischemic complications. Use symptomatic calcium-channel blockade with this limitation in mind; clinical worsening, seizure, focal deficit, or new severe headache should trigger reassessment for infarction, hemorrhage, CVT, dissection, or an alternative diagnosis rather than escalation based on headache response alone. [10][24]" ], "bullets": [ "Document vascular reversibility by 3 months to satisfy the RCVS diagnostic framework. [6][11]", "Do not infer a benign course solely from a normal initial CT or MRI, because ischemic and hemorrhagic complications can occur after initially normal imaging. [10][17]" ] } ], "table": { "caption": "Features that separate RCVS from major thunderclap headache mimics. [3][6][16][17]", "columns": [ "Discriminator", "RCVS pattern", "Competing diagnosis and next test" ], "rows": [ [ "Headache trajectory", "Recurrent thunderclap attacks over 1–3 weeks, often trigger-associated. [16]", "Single explosive event should sustain concern for aneurysmal SAH; use CT and, if needed, CSF assessment. [1][5]" ], [ "Vascular imaging", "Segmental multifocal narrowing in at least two cerebral arteries, resolving by 3 months. [6]", "Cervical arterial imaging abnormality suggests dissection; pursue CTA/MRA of head and neck. [1][24]" ], [ "Postpartum state or sulcal hemorrhage", "Can occur with RCVS. [3][17]", "CVT/cortical vein thrombosis also becomes a major alternative; obtain MRI with susceptibility imaging and MRV. [17]" ], [ "Parenchymal imaging", "May be normal; abnormalities reported in 31% in one RCVS comparison cohort. [6]", "Abnormal CT/MRI is more typical of PACNS in that comparison; maintain diagnostic evaluation for CNS vasculitis when the overall pattern is atypical for RCVS. [6]" ] ] } }, { "id": "alternate-etiologies", "eyebrow": "Targeted Differential", "heading": "Select Imaging for Venous, Cervical Arterial, Sellar, and Pressure Disorders", "intro": "Normal CT and CSF redirect testing according to phenotype rather than ending the evaluation.", "paragraphs": [ "For suspected CVT or cortical vein thrombosis, obtain brain MRI with susceptibility-sensitive sequences and MR venography. Cortical vein thrombosis can produce both thunderclap headache and convexity subarachnoid hemorrhage, and postpartum patients have increased risk for both CVT and RCVS; this overlap makes venous imaging particularly important in that setting. [17][19]", "Obtain CTA or MRA of cervical and cerebral vessels when cervical artery dissection is plausible or when CT and CSF are normal but the thunderclap phenotype remains unexplained. Dissection may present with isolated thunderclap headache and a normal neurologic examination, CT, and CSF profile. [1][24]", "Use brain MRI when clinical features raise concern for posterior circulation infarction, pituitary apoplexy, spontaneous intracranial hypotension, infection, or a third-ventricle colloid cyst. These disorders are recognized thunderclap headache causes, and diffusion MRI is more sensitive than early CT for cerebellar infarction. [1][15][22][23]", "Consider posterior reversible encephalopathy syndrome when thunderclap headache occurs with compatible clinical or imaging findings, especially because it overlaps with RCVS and can accompany its vascular complications. Brain MRI is the imaging modality that clarifies parenchymal involvement after initial CT screening. [3][17][24]" ], "bullets": [ "Do not diagnose primary thunderclap headache until targeted evaluation has found no secondary cause. [15][23]", "Escalate promptly for new seizure, focal neurologic deficit, or imaging evidence of infarction, hemorrhage, venous thrombosis, or arterial dissection; these findings identify a disease-specific treatment pathway rather than isolated headache management. [3][11][17]" ], "subsections": [], "table": { "caption": "Phenotype-directed studies after initial hemorrhage evaluation. [1][17][22][24]", "columns": [ "Clinical or imaging clue", "Condition to prioritize", "Most useful next study" ], "rows": [ [ "Postpartum state, convexity sulcal SAH, or unexplained recurrent thunderclap headache", "CVT/cortical vein thrombosis", "MRI with susceptibility sequences plus MRV. [17]" ], [ "Normal CT/CSF with persistent concern for vascular cause", "Cervical artery dissection or RCVS", "CTA or MRA of cerebral and cervical arteries. [1][24]" ], [ "Concern for early posterior circulation ischemia", "Cerebellar infarction", "Diffusion-weighted brain MRI. [22]" ], [ "Sellar, intracranial-pressure, infectious, or obstructive phenotype", "Pituitary apoplexy, spontaneous intracranial hypotension, intracranial infection, or colloid cyst", "Brain MRI directed to the suspected structural process. [1][15][23]" ] ] } }, { "id": "disposition-and-follow-up", "eyebrow": "Monitoring", "heading": "Use the Clinical Course and Repeat Imaging to Close the Diagnostic Loop", "intro": "Diagnostic certainty in RCVS depends on trajectory and vascular reversibility.", "paragraphs": [ "Monitor patients with suspected or confirmed RCVS for recurrent thunderclap attacks and delayed ischemic or hemorrhagic complications during the active period, because stroke can occur days after initially normal imaging and angiographic vasoconstriction can intensify over subsequent weeks. New focal symptoms, seizure, or abrupt clinical deterioration should prompt repeat parenchymal and vascular imaging. [10][11][17]", "Arrange follow-up vascular imaging to document resolution of arterial narrowing by 3 months. Lack of reversibility should reopen the differential, including PACNS and structural vasculopathy, rather than retaining a presumptive RCVS diagnosis. [6][11]", "For patients with normal examination, CT, and CSF in whom no syndrome-specific clinical trigger, focal feature, or imaging abnormality remains, further angiography is not required solely to exclude SAH. Conversely, recurrent attacks, postpartum status, vasoactive exposures, or clinical clues to venous thrombosis, dissection, stroke, or pituitary disease justify disease-directed imaging despite a negative CT/LP evaluation. [8][1][17][24]" ], "bullets": [ "Use transcranial Doppler as an adjunctive monitoring tool when available; early studies can be normal, so a normal initial velocity does not exclude evolving RCVS. [11]", "Counsel patients with suspected RCVS to avoid identified vasoactive triggers and document all potentially implicated medications and substances for reconciliation and follow-up. [6][24]" ], "subsections": [], "table": { "caption": "Follow-up decisions after negative initial CT and CSF. [1][6][8][20]", "columns": [ "Follow-up finding", "Interpretation", "Action" ], "rows": [ [ "No recurrence, normal examination, no syndrome-specific concern", "SAH is very unlikely after normal CT and CSF. [8]", "No angiography solely for SAH exclusion. [8]" ], [ "Recurrent thunderclap headaches or characteristic triggers", "Possible evolving RCVS despite initially negative vascular imaging. [16][20]", "Repeat CTA/MRA or consider digital subtraction angiography; follow clinically for complications. [20][24]" ], [ "New deficit, seizure, or new severe headache", "Possible delayed infarction, hemorrhage, or alternate vascular diagnosis. [10][11][17]", "Repeat brain and vascular imaging urgently. [17]" ], [ "Persistent arterial narrowing at follow-up", "Does not meet expected RCVS reversibility. [6]", "Reassess for PACNS and other vasculopathies. [6]" ] ] } } ], "faq": [], "references": [ { "number": 1, "title": "Thunderclap headache | The BMJ", "detail": "www.bmj.com", "url": "https://www.bmj.com/content/346/bmj.e8557", "authors": "www.bmj.com", "host": "www.bmj.com" }, { "number": 2, "title": "Reversible Cerebral Vasoconstriction Syndromes", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=NEUR&pdfFileName=noc15014_1005_1012.pdf", "authors": "jamanetwork.com", "host": "jamanetwork.com" }, { "number": 3, "title": "Reversible Cerebral Vasoconstriction Syndrome and Female Sex: A Narrative Review | Stroke", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/10.1161/STROKEAHA.123.046312", "authors": "www.ahajournals.org", "host": "www.ahajournals.org" }, { "number": 4, "title": "Migraine", "detail": "www.acpjournals.org", "url": "https://www.acpjournals.org/doi/pdf/10.7326/AITC202301170", "authors": "www.acpjournals.org", "host": "www.acpjournals.org" }, { "number": 5, "title": "Scientific Rationale for the Inclusion and Exclusion Criteria for ...", "detail": "stroke.ahajournals.org", "url": "http://stroke.ahajournals.org/content/strokeaha/early/2015/12/22/STR.0000000000000086.full.pdf", "authors": "stroke.ahajournals.org", "host": "stroke.ahajournals.org" }, { "number": 6, "title": "Reversible Cerebral Vasoconstriction Syndrome | Stroke - AHA/ASA Journals", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.119.024416", "authors": "www.ahajournals.org", "host": "www.ahajournals.org" }, { "number": 7, "title": "Thunderclap Headache With Normal CT and Lumbar Puncture | Stroke", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/10.1161/strokeaha.107.503169", "authors": "www.ahajournals.org", "host": "www.ahajournals.org" }, { "number": 8, "title": "Thunderclap Headache With Normal CT and Lumbar Puncture", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/10.1161/STROKEAHA.107.503151", "authors": "www.ahajournals.org", "host": "www.ahajournals.org" }, { "number": 9, "title": "Thunderclap headache", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1474442206704975", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 10, "title": "THUNDERCLAP HEADACHE: SYMPTOM OF UNRUPTURED CEREBRAL ANEURYSM - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0140673686926772", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 11, "title": "Reversible cerebral vasoconstriction syndrome - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/pii/S1474442212701357", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 12, "title": "Thunderclap Headache: Presentation of Intracranial Sinus Thrombosis? 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Verify recommendations against current guidance and patient-specific factors.", "citations": [ { "number": 1, "title": "Thunderclap headache | The BMJ", "detail": "www.bmj.com", "url": "https://www.bmj.com/content/346/bmj.e8557", "authors": "www.bmj.com", "host": "www.bmj.com", "snippet": "Toggle navigation The BMJ logo. # Thunderclap headache. 1. 1Emergency Headache Centre, Head and Neck Clinic, Lariboisière Hospital, Assistance Publique Hôpitaux de Paris, 75010 Paris, France. 2. 2Neurology Department, Head and Neck Clinic, Lariboisière Hospital. * Thunderclap headache is a severe he", "score": 0.78532547 }, { "number": 2, "title": "Reversible Cerebral Vasoconstriction Syndromes", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=NEUR&pdfFileName=noc15014_1005_1012.pdf", "authors": "jamanetwork.com", "host": "jamanetwork.com", "snippet": "Onset with thunderclap headache was docu- mented in 85% includes aneurysmal SAH, pituitary apoplexy, and cerebral venous sinus thrombosis.24", "score": 0.6914979 }, { "number": 3, "title": "Reversible Cerebral Vasoconstriction Syndrome and Female Sex: A Narrative Review | Stroke", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/10.1161/STROKEAHA.123.046312", "authors": "www.ahajournals.org", "host": "www.ahajournals.org", "snippet": "Segmental, multifocal constriction of intracranial arteries in addition to sudden painful, recurrent headaches characterizes reversible cerebral vasoconstriction syndrome (RCVS).1 A neurovascular disorder that can result in ischemic stroke, intracranial hemorrhage (including intracerebral hemorrhage", "score": 0.6628188 }, { "number": 4, "title": "Migraine", "detail": "www.acpjournals.org", "url": "https://www.acpjournals.org/doi/pdf/10.7326/AITC202301170", "authors": "www.acpjournals.org", "host": "www.acpjournals.org", "snippet": "women include cerebral venous throm- bosis, pituitary apoplexy, cervical artery dissection, and headache after epidu- ral anesthesia during delivery. Neuro", "score": 0.3835264 }, { "number": 5, "title": "Scientific Rationale for the Inclusion and Exclusion Criteria for ...", "detail": "stroke.ahajournals.org", "url": "http://stroke.ahajournals.org/content/strokeaha/early/2015/12/22/STR.0000000000000086.full.pdf", "authors": "stroke.ahajournals.org", "host": "stroke.ahajournals.org", "snippet": "A lumbar puncture is generally advised as the next step after a negative head noncontrast CT in the evaluation of patients with thunderclap headache", "score": 0.6651719 }, { "number": 6, "title": "Reversible Cerebral Vasoconstriction Syndrome | Stroke - AHA/ASA Journals", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.119.024416", "authors": "www.ahajournals.org", "host": "www.ahajournals.org", "snippet": "Bushnell, MD, MHS cbushnel@wakehealth.eduAuthor Info & Affiliations ### Metrics ### Total Downloads42,209 ### Total Citations64 Reversible cerebral vasoconstriction syndrome (RCVS) is used to describe a multitude of pathologies encompassing the clinical terms Call-Fleming syndrome, thunderclap heada", "score": 0.62523276 }, { "number": 7, "title": "Thunderclap Headache With Normal CT and Lumbar Puncture | Stroke", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/10.1161/strokeaha.107.503169", "authors": "www.ahajournals.org", "host": "www.ahajournals.org", "snippet": "In addition to SAH, a large number of conditions can present with an explosive headache and a normal head CT (Table).1,2 For most of these conditions the diagnosis rests on the performance of additional investigations. A retrospective study of unselected patients presenting with thunderclap headache", "score": 0.6188962 }, { "number": 8, "title": "Thunderclap Headache With Normal CT and Lumbar Puncture", "detail": "www.ahajournals.org", "url": "https://www.ahajournals.org/doi/10.1161/STROKEAHA.107.503151", "authors": "www.ahajournals.org", "host": "www.ahajournals.org", "snippet": "Thunderclap Headache With Normal CT and Lumbar Puncture | Stroke. Thunderclap Headache With Normal CT and Lumbar Puncture: Further Investigations Are Unnecessary: For. Sean I.Savitz, MD, and Jonathan Edlow, MDAuthor Info & Affiliations. Patients with thunderclap headache and a normal examination, CT", "score": 0.6010557 }, { "number": 9, "title": "Thunderclap headache", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1474442206704975", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Thunderclap headache (TCH) is head pain that begins suddenly and is severe at onset. TCH might be the first sign of subarachnoid haemorrhage, unruptured intracranial aneurysm, cerebral venous sinus thrombosis, cervical artery dissection, acute hypertensive crisis, spontaneous intracranial hypotensio", "score": 0.78014404 }, { "number": 10, "title": "THUNDERCLAP HEADACHE: SYMPTOM OF UNRUPTURED CEREBRAL ANEURYSM - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0140673686926772", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Title: THUNDERCLAP HEADACHE: SYMPTOM OF UNRUPTURED CEREBRAL ANEURYSM - ScienceDirect\n# THUNDERCLAP HEADACHE: SYMPTOM OF UNRUPTURED CEREBRAL ANEURYSM. Many patients with a ruptured berry aneurysm report an intense sentinel headache of sudden onset in the weeks before rupture. A case is reported of a ", "score": 0.7752821 }, { "number": 11, "title": "Reversible cerebral vasoconstriction syndrome - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/pii/S1474442212701357", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Recurrent thunderclap headaches, seizures, strokes, and non-aneurysmal subarachnoid haemorrhage can all reveal reversible cerebral vasoconstriction syndrome. Reversible cerebral vasoconstriction syndrome (RCVS) is characterised by severe headaches, with or without other acute neurological symptoms, ", "score": 0.7752821 }, { "number": 12, "title": "Thunderclap Headache: Presentation of Intracranial Sinus Thrombosis? - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0009926003001740", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Title: Thunderclap Headache: Presentation of Intracranial Sinus Thrombosis? - ScienceDirect\n# Case Report Thunderclap Headache: Presentation of Intracranial Sinus Thrombosis? Intracranial sinus thrombosis (ICST) and subarachnoid haemorrhage (SAH) are common presentations to neuroscience departments,", "score": 0.7230167 }, { "number": 13, "title": "Reversible Cerebral Vasoconstriction Syndrome: An Important Cause of Acute Severe Headache - Tan - 2012 - Emergency Medicine International - Wiley Online Library", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1155/2012/303152", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "# Reversible Cerebral Vasoconstriction Syndrome: An Important Cause of Acute Severe Headache. Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of acute headache. Reversible cerebral vasoconstriction syndrome (RCVS) is one of these differentials t", "score": 0.67988104 }, { "number": 14, "title": "Thunderclap headache: an update - PubMed", "detail": "www.ncbi.nlm.nih.gov", "url": "https://www.ncbi.nlm.nih.gov/pubmed/30334463", "authors": "www.ncbi.nlm.nih.gov", "host": "www.ncbi.nlm.nih.gov", "snippet": "Title: Thunderclap headache: an update - PubMed\nAn official website of the United States government. **The .gov means it’s official.**. Federal government websites often end in .gov or .mil. sharing sensitive information, make sure you’re on a federal. The **https://** ensures that you are connectin", "score": 0.8315952 }, { "number": 15, "title": "Thunderclap headache: an approach to a neurologic emergency - PubMed", "detail": "www.ncbi.nlm.nih.gov", "url": "https://www.ncbi.nlm.nih.gov/pubmed/17324359", "authors": "www.ncbi.nlm.nih.gov", "host": "www.ncbi.nlm.nih.gov", "snippet": "Title: Thunderclap headache: an approach to a neurologic emergency - PubMed\nAn official website of the United States government. **The .gov means it’s official.**. Federal government websites often end in .gov or .mil. sharing sensitive information, make sure you’re on a federal. The **https://** en", "score": 0.75290436 }, { "number": 16, "title": "Reversible Cerebral Vasoconstriction Syndrome, Part 1: Epidemiology, Pathogenesis, and Clinical Course", "detail": "www.ajnr.org", "url": "https://www.ajnr.org/content/36/8/1392", "authors": "www.ajnr.org", "host": "www.ajnr.org", "snippet": "Thunderclap headache is not specific for RCVS and can be associated with various other medical conditions, including aneurysmal subarachnoid hemorrhage, primary headache disorder, pituitary apoplexy, cerebral venous sinus thrombosis, unruptured cerebral aneurysm, cervical arterial dissection, and th", "score": 0.7487387 }, { "number": 17, "title": "Reversible Cerebral Vasoconstriction Syndrome, Part 2: Diagnostic Work-Up, Imaging Evaluation, and Differential Diagnosis", "detail": "www.ajnr.org", "url": "https://www.ajnr.org/content/36/9/1580", "authors": "www.ajnr.org", "host": "www.ajnr.org", "snippet": "Cortical vein thrombosis is another potential cause of both thunderclap headache and convexity subarachnoid hemorrhage and should be considered in the differential diagnosis with RCVS in the appropriate clinical setting. Postpartum women are one specific subgroup of patients who are at increased ris", "score": 0.69099766 }, { "number": 18, "title": "Reversible Cerebral Vasoconstriction Syndrome, Part 1", "detail": "www.ajnr.org", "url": "https://www.ajnr.org/content/ajnr/36/8/1392.full.pdf", "authors": "www.ajnr.org", "host": "www.ajnr.org", "snippet": "by TR Miller · 2015 · Cited by 293 — Thunderclap headache is not specific for RCVS and can be associated with various other medical conditions, including an- eurysmal subarachnoid hemorrhage,", "score": 0.6698534 }, { "number": 19, "title": "Isolated Acute Nontraumatic Cortical Subarachnoid ...", "detail": "www.ajnr.org", "url": "https://www.ajnr.org/content/31/8/1355", "authors": "www.ajnr.org", "host": "www.ajnr.org", "snippet": "by V Cuvinciuc · 2010 · Cited by 190 — The thunderclap headache is mostly seen in younger patients and is more specific for CVT or RCVS. Patients with such symptoms should undergo", "score": 0.52290934 }, { "number": 20, "title": "Reversible Cerebral Vasoconstriction Syndrome and Thunderclap Headache: A Diagnostic Challenge (P2-12.001)", "detail": "www.neurology.org", "url": "https://www.neurology.org/doi/10.1212/WNL.0000000000208142", "authors": "www.neurology.org", "host": "www.neurology.org", "snippet": "# Reversible Cerebral Vasoconstriction Syndrome and Thunderclap Headache: A Diagnostic Challenge (P2-12.001) Carolina Perez Arana, Gustavo Portuondo, Emanuel Garat, Virginia Pujol, and Maria Teresa GoicocheaAuthors Info & Affiliations ## Abstract ### Objective: Reversible Cerebral Vasoconstriction S", "score": 0.6188962 }, { "number": 21, "title": "A common cause of sudden and thunderclap headaches: reversible cerebral vasoconstriction syndrome - PubMed", "detail": "www.ncbi.nlm.nih.gov", "url": "https://www.ncbi.nlm.nih.gov/pubmed/24580731", "authors": "www.ncbi.nlm.nih.gov", "host": "www.ncbi.nlm.nih.gov", "snippet": "Title: A common cause of sudden and thunderclap headaches: reversible cerebral vasoconstriction syndrome - PubMed\n## Save citation to file. ## Email citation. Go to My NCBI account settings to confirm your email and then refresh this page. # A common cause of sudden and thunderclap headaches: reve", "score": 0.52232456 }, { "number": 22, "title": "Thunderclap Headache - an overview", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/topics/nursing-and-health-professions/thunderclap-headache", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Besides subarachnoid hemorrhage, thunderclap headache may be the presenting symptom of several other vascular and nonvascular disorders (Ducros, 2005; Schwedt et al., 2006). Other intracranial hemorrhages, notably cerebellar or intraventricular, are responsible for 5–10% of thunderclap headaches, an", "score": 0.6852132 }, { "number": 23, "title": "Thunderclap headache: Diagnostic considerations and ...", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0009926012005272", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Thunderclap headache (TCH) is an acute and severe headache that has maximum intensity at onset; TCH can be primary or secondary. Primary TCH is diagnosed when no underlying cause is discovered; however, imaging is crucial in distinguishing secondary causes, which are wide-ranging. The radiologist sh", "score": 0.6829338 }, { "number": 24, "title": "The Thunderclap Headache: Approach and Management in the Emergency Department", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0736467919300344", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "TCH is a symptom associated with several significant diseases. The most common diagnosed condition is subarachnoid hemorrhage (SAH). Other diagnoses include reversible cerebral vasoconstriction syndrome, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy synd", "score": 0.6826801 } ], "publishedAt": "2026-08-24T16:35:56.275083+00:00", "updatedAt": "2026-08-24T16:35:56.275083+00:00", "readingMinutes": 7, "slug": "thunderclap-headache" }