Thunderclap headache
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.e8557 (Published 09 January 2013) Cite this as: BMJ 2013;346:e8557
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The authors have advocated the practice of visual inspection of cerebrospinal fluid (CSF) to detect if CSF blood pigments are present, which may indicate the occurrence of sub-arachnoid haemorrhage. This practice is highly subjective and generates false positive and false negative results, which could ultimately result in miss-treatment of patients and may prove fatal and therefore is not recommended.
The Revised National Guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage state that visual inspection is not a reliable method for detecting bilirubin in CSF samples. These guidelines are utilised by the laboratories that perform the analysis of bilirubin CSF testing nationally.
We therefore recommend the following:
“A lumbar puncture is needed in patients with a thunderclap headache after normal brain imaging. Yellow coloration (xanthochromia) on visual inspection of the supernatant is not a reliable test for subarachnoid haemorrhage and spectrophotometry for detecting bilirubin formed in vivo is required to make a diagnosis of subarachnoid haemorrhage.”
References relevant to this matter are as follows:
Revised National Guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage. Cruickshank A, Auld P, Beetham R, Burrows G, Egner W, Holbrook I, Keir G, Lewis E, Patel D, Watson I, White P, UK NEQAS Specialist Advisory Group for External Quality Assurance of CSF Proteins and Boichemistry. Ann Clin Biochem 2008 May; 45 (Pt3): 238-44
Kjellin KG, Soderstrom CE. Diagnostic significance of CSF spectrophotometry in cerebrovascular diseases. J Neurol Sci 1974;23 :359-69
Marden NA, Thomas PH, Syansbie D. Is the naked eye as sensitive as the spectrophotometer for detecting xanthochromia in cerebrospinal fluid? In: Martin SM, ed. Proceedings of the National Meeting, 30 April-4 May 2001, London. London: Association of Clinical Biochemists 2001:53.
Competing interests: No competing interests
Ducros et al provided a comprehensive review of the investigation and management of thunderclap headache [1]. We would suggest that an ECG be added to the list of mandatory investigations in such patients.
It is well known that primary intra-cranial pathology such as sub-arachnoid haemorrhage can cause ECG changes and cardiac enzyme release. However, myocardial ischaemia presenting with headache is less well recognised. We and others have reported the extremely rare scenario of thunderclap headache as the sole presenting symptom of acute ST-elevation myocardial infarction [2-4]. Although rare, a simple ECG would allow the identification of such patients who, following prompt exclusion of intra-cranial pathology, can be urgently referred to cardiology for consideration of optimal reperfusion therapy.
References
[1] Ducros A, Bousser MG. Thunderclap headache. BMJ. 2013;346:e8557.
[2] Broner S, Lay C, Newman L, Swerdlow M. Thunderclap headache as the presenting symptom of myocardial infarction. Headache. 2007;47:724-5.
[3] Seow VK, Chong CF, Wang TL, Ong JR. Severe explosive headache: a sole presentation of acute myocardial infarction in a young man. Am J Emerg Med. 2007;25:250-1.
[4] Dalzell JR, Jackson CE, Robertson KE, McEntegart MB, Hogg KJ. A case of the heart ruling the head: acute myocardial infarction presenting with thunderclap headache. Resuscitation. 2009;80:608-9.
Competing interests: No competing interests
This is an excellent review of the management of patients presenting with thunderclap headache. However, I feel that it could be misleading with regards to the management of the acute severe headache in the neurologically intact patient. The article defines thunderclap headache as a severe headache that peaks within 60 seconds of onset. Although this is an acceptable definition it is important to be aware that with traditional diagnoses associated with thunderclap headache it can take longer than this for maximal intensity of pain to be reached.
Perry et al recruited 1999 patients with acute headache defined as peak onset within an hour or associated with syncope. Within this population there were 130 cases of subarachnoid haemorrhage and 48 other causes of secondary headache. A ‘severe headache’ was not part of the inclusion criteria, most patients presenting to an unscheduled care setting with a chief complaint of headache will consider their headache to be severe.
Although I appreciate that this article is focused on the thunderclap headache, patients presenting with an acute headache peaking within an hour or associated with syncope should be considered to have a secondary cause.
High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
Jeffrey J Perry, Ian G Stiell, Marco L A Sivilotti, Michael J Bullard, Jacques S Lee, Mary Eisenhauer, Cheryl Symington, Melodie Mortensen, Jane Sutherland, Howard Lesiuk, George A Wells
BMJ 2010;341:c5204 (Published 28 October 2010)
Competing interests: No competing interests
I was rather surprised that the authors had not included phaeochromocytoma among the differential diagnoses. Sudden emptying of catecholamine from the tumour into the general circulation will cause paroxysmal episodes of hypertension resulting in severe, pulsating, thunderclap headaches maximal in the occipital region which reach a climax within a few seconds and last for several minutes or longer. The episodes can be triggered by straining at stool, sexual activity, assuming a horizontal posture etc. The immediate response of the patient is usually to stand up and hold onto something for support.
It is of the utmost importance that phaeochromocytoma should be considered in the diagnosis of thunderclap headache as the condition is eminently treatable and left undiagnosed will inevitably be fatal.
Competing interests: No competing interests
The authors note a risk of 2% of subarachnoid haemorrhage with a negative CT scan. This is based on a review article from 2000 which in turn references to a case series from 1995. It has been suggested that modern scanners have a higher sensitivity particularly within 6 hours of onset of symptoms.
Perry JJ et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: Prospective cohort study. BMJ 2011 Jul 18; 343:d4277. (http://dx.doi.org/10.1136/bmj.d4277)
showed all 121 patients with haemorrhage scannned within 6 hours had it picked up.
Competing interests: No competing interests
This is a much welcomed and detailed review of the aetiology of thunderclap headache which is an entity all too well known to neurology registrars providing telephone advice and ward consults to colleagues dealing with the acute medical take.
With reference to box 4 identifying the secondary causes of thunderclap headache, I would like to highlight the importance of disorders of CSF pressure as potential secondary causes of thunderclap headache (idiopathic intracranial hypertension, cerebral venous sinus thrombosis and spontaneous or secondary intracranial hypotension). In addition, I would highlight the importance of the accurate recording of opening pressure in the patient's chart when performing a diagnostic lumbar puncture. Personally, I prefer to classify CSF results as normal or abnormal where possible and the concept of 'near normal' may be confusing. In the setting of thunderclap headache with 'normal' plain CT and an isolated raised protein and/or raised opening pressure cerebral venous sinus trombosis and subsequent venous imaging should be considered.
It is also important to reiterate the importance of a fundoscopic examination at the time of admission as the presence of disc swelling and a 'near normal' lumbar puncture raises the possibility of idiopathic intracranial hypertension or indeed other secondary causes. The International Headache Society classification of headache disorders (second edition) has a useful section on exclusion criteria for 'primary thunderclap headache'(section 4.6) that highlights relevant secondary causes of thunderclap headache.
Reference:International Headache Society classification of headache disorders available at www.ihs-classification.org/en/
Competing interests: No competing interests
Re: Thunderclap headache
As the authors state, there is ongoing debate over the need for further investigations in patients who have thunderclap headache with normal CT and lumbar puncture results [1].
In some patients, a thunderclap headache may subside and they may not seek medical attention. In the context of SAH, this is termed sentinel headache/ haemorrhage or warning headache.
If the headache is accompanied by a low volume subarachnoid bleed, this will be identified on a CT head or lumbar puncture.
However, as case reports indicate, warning headaches may occur due to aneurysmal enlargement [2,3]. In such cases, plain CT head and lumbar puncture results will be normal.
We agree with the authors that a high-index of suspicion should be maintained in such cases, and if necessary a CT/MR angiogram may have to be performed looking for an aneurysm.
1. Thunderclap headache. Dodick DW. J Neurol Neurosurg Psychiatry 2002; 72:6-11.
2. Thunderclap headache: symptom of unruptured cerebral aneurysm. Day JW, Raskin NH. Lancet 1986; 2:1247-8.
3. Unruptured cerebral aneurysm producing a thunderclap headache. Witham TF, Kaufmann AM. Am J Emerg Med 2000; 18:88-90.
Competing interests: No competing interests