Thunderclap Headache: Overview, Causes, Sign and Treatment


The thunderclap headache is the type of headache with begins over suddenly and the intensity of the pain does not increase gradually but the pain Rises suddenly. It may be due to a life-threatening condition and is a sign that there is some kind of ongoing bleeding occurring inside your brain. The significant common cause of this headache is a recognized hemorrhage and it is very less common as compared to ischemic or intracerebral hemorrhage. Women are more prone to get suffer from this condition as compared to male and age is usually less than 65.

Causes of Thunderclap Headache

More than 90% of the causes of this type of headache occurs due to dilations in the vessels. The dilations are shaped as berry or saccular type. The most common region involved in causing hemorrhage is the separation of cerebral arteries in the region of the circle of Willis anterior communicating artery, posterior communicating artery or middle cerebral artery.

if the first-degree relative is suffering from thunderclap headache, it is a possibility that the patient will suffer as well. Increased risk in patients with Ehler Danlos syndrome, Polycystic kidney disease, and connective tissue disorders.

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The mortality from thunderclap headache is very high and it is due to arterial malformations and cerebral artery dissection.

Signs and Symptoms

  • Subarachnoid hemorrhage typically presents when the patient suffers from a severe headache which is a thunderclap headache and is most pronounced in the occipital region a least for seven days.
  • it is manifested by vomiting, neck stiffness, pain, and raised blood pressure.
  • The signs and symptoms of hemorrhage occur on staining, sexual excitement, and physical exertion, and also there may be a loss of consciousness.
  • There is a possibility of severe sudden headache and that in 1 patient out of 8.
  • When we examine the patient of a thunderclap headache, he is distressed, irritable, and has photophobia.
  • There is neck stiffness due to blood in the subarachnoid space and it may take a few hours to develop. There may be aphasia or difficulty in speaking.
  • Third Nerve Palsy occurs due to local pressure of the aneurysm on the posterior communicating artery but this condition is really rare. if we perform a fundoscopy of hemorrhage there will be the Tram track appearance of blood vessels around the optic nerve.

Other symptoms the patient may suffer due to compression of neighboring cranial nerves by a blood clot are visual field defects, 3rd 4th and 6th nerve involvement, and hemiplegia or hemiparesis.

Laboratory Examination

  • CT scan

City scan is the investigation of choice and 90% of cases will demonstrate the blood in subarachnoid space.

If the negative result is present on a CT Scan, this test does not completely exclude subarachnoid hemorrhage as a small amount of the blood in the subarachnoid space cannot be detected on a CT scan.

  • Lumbar puncture

Lumbar puncture is performed after 12 hours of the onset of symptoms. If the color of the fluid is Yellow or red which is referred to as xanthochromia there is a possibility of subarachnoid hemorrhage.

The lumbar puncture result in herniation of brain tissue due to rising in the intracerebral pressure, therefore, it is not performed routinely but when CT scan does not provide an adequate assessment, a lumbar puncture can be performed in acute emergency situations.

  • Cerebral angiography

If either of the tests of the city scan for a lumbar puncture is positive then cerebral angiography is required to determine the site to prevent the recurrent bleeding and causing thunderclap headache.

Supportive Therapy

  • the care of the eyes is done so as to prevent xerostomia
  • the frequent position Changing of patients so as to prevent the bedsores
  • An intravenous line is passed and feeding is done
  • enema is given to the patient to prevent constipation
  • frequent suctioning is done to improve the respiratory distress

How To Treat Thunderclap Headache?

Mostly the patient of subarachnoid hemorrhage dies in a few days or at the spot. If the patient undergoes or has other neurological deficits he has a poor prognosis and we not live.

  • Nimodipine

 nimodipine 3260 milligram IV is given for 1-2 weeks and then followed by 360 milligrams given orally for the seven days. It is usually given to prevent the decreased oxygen supply in acute phases

  • Insertion of platinum coils

The platinum coils are inserted into the duration of the surgical clipping of aneurysm. It produces protection from the early and late cases of the aneurysm. But there as a possibility of perioperative complications.

  • Arteriovenous malformations

Arteriovenous malformations can be either done by surgical removal or nipping the blood vessels at the draining of feeding the aneurysm or by inserting the metal coil inside it so as to block the draining veins and fistula.

  • Control of hypertension

Blood pressure is usually raised in thunderclap headache and antihypertensive drugs like beta-blockers and Calcium channel blockers are given to the patient to control hypertension which may further exacerbate the symptoms of subarachnoid hemorrhage.

  • Seizures prophylaxis

The increase in blood pressure in subarachnoid hemorrhage and thunderclap headache main cause seizures in the patient and the seizures prophylaxis procedure is required. Sodium valproate is usually given to control the seizures prophylactically in patients suffering from thunderclap headache.

  • Reduce cerebral edema

Cerebral edema is usually reduced by giving dexamethasone to the patient. The dexamethasone will cause a reduction of edema and will not lead the condition to exacerbate.

Prognosis of Thunderclap Headache

The prognosis of thunderclap headache is very poor. Usually, the patient dies at the spot or may undergo a large number of various neurological deficits. The patients need regular assessment and care which will improve the prognosis. The complications of subarachnoid hemorrhage should also be treated as well to improve the prognosis of subarachnoid hemorrhage.

Complications of Thunderclap Headache

The complications of subarachnoid hemorrhage are ranging from, neurological deficits, coma, and even death of the patient.

Few of the Other complications which the patient may suffer are:

  • obstructive hydrocephalus due to vasospasm
  • hyponatremia
  • Decreased mobility
  • Aphasia
  • paralysis
  • chest infections
  • venous thrombosis

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The term thunderclap headache occurs due to spontaneous rather than traumatic order bleeding at the subarachnoid space. It is an emergency and warrants medical help as soon as possible. Most of the subarachnoid hemorrhage resulting from the rupture of Berry aneurysm due to cerebral arteries at the circle of Willis.

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