Summary
Thunderclap headaches are a type of headache marked by sudden, sharp, intense and unbearable pain that can last up to a minute. The intense pain will subside, while mild pain can last up to 72 hours. There are two types of thunderclap headaches and their causes vary accordingly, although symptoms can be similar. Once the necessary diagnostic tests are done, treatment depends on what is the underlying cause.
Introduction
Headaches are a common condition and one has experienced them at least once in a lifetime. According to neurosurgeons, there are different types of headaches, with their own underlying cause and triggers. There are pain-sensitive nerve-endings called nociceptors located all over the body. Sometimes they react strongly to stress, lack of sleep, certain foods, incorrect spectacles, certain odours, loud noise, certain medicines and tight headgear. They send messages through the trigeminal nerve to the thalamus located in the brain. The thalamus is the main processing centre in the brain for pain sensation anywhere in the body. This intense messaging causes headaches. This is the general pathology of headaches.
Then there are migraine headaches in which certain brain cells get highly excited and undergo waves of activity. In response, the hormone serotonin is produced which causes blood-vessels to narrow. One of the consequences of this is headache.
Thunderclap headaches are another class of headaches. In this, the person experiences sudden and intense pain like he/she has never experienced before with the pain being unbearable. That is why it is compared to a thunderclap. The intense pain or the ‘peak’ lasts for a minute to 90 seconds. Then the peak subsides and there is a less intense pain which can last up to 72 hours. In some people, the condition can recur in the days or weeks following the first peak.
Types
- Primary: In this type, there is no underlying cause for the headache, and the condition is not serious. Some of the triggers for this type are listed under the section Triggers below. Once the triggers go away, the headache also goes away.
- Secondary: In this type, the headache has a clear and underlying cause, which is a serious condition in itself. These are listed in the following section. Treatment for secondary thunderclap headache involves treating the underlying causes.
Causes
- Subarachnoid haemorrhage which is a bleeding between the brain and tissues covering the brain. This is the most common cause
- RCVS or Reversible cerebral vasoconstriction syndrome. In this, there is a sudden constriction of the blood-vessels that supply blood to the brain. This is the second most common cause.
- A rupture of a blood vessel in the brain, due to aneurysm or hypertension
- A tear in the lining of an artery in the head or neck region that supplies blood to the brain, causing bleeding in the areas surrounding the brain: called Cervical artery dissection
- Cerebrospinal fluid is a fluid that surrounds the brain and spinal cord, and serves various functions. When there is a tear in the covering around a nerve root in the spine, this fluid can leak. Then thunderclap headaches are one of the symptoms
- Pituitary gland related – when tissues in the gland start dying out, or if there is bleeding in the gland, or blockage in blood-flow to the gland
- A blood clot in the brain (cerebral thrombosis)
- Sudden and severe elevation in blood-pressure (called hypertensive crisis)
- Infections that affect the brain such as encephalitis or meningitis
- Ischemic stroke due to disrupted blood-supply to the brain
- Trauma, or head injury that causes bleeding in the brain
- Late-term pregnancy complications such as eclampsia (results in hypertension) and bleeding in the pituitary gland, either during pregnancy or following delivery.
- Carcinoid tumours and Pheochromocytoma
- Haemorrhagic stroke
- Vasculitis, or inflammation of a blood vessel in the brain
- Blocked veins in the head
- Leaking spinal fluid
- Cerebral venous sinus thrombosis occurs when a blood clot forms within a large vein in the brain.
- Spontaneous intracranial hypotension: In this condition, a low pressure is formed within the skull due to reduction in cerebrospinal fluid
- Meningitis, which is an inflammation of the membranes surrounding the brain and spinal cord.
- Acute sinusitis: An inflammation of the nasal passage caused by rapid changes in air pressure (called barotrauma).
- A colloid cyst of the third ventricle: This is a benign (non-cancerous) growth in the third ventricle, which is a narrow cavity in the brain’s centre
- Pituitary apoplexy: In this condition, a tumour in the pituitary gland starts bleeding or outgrows its blood supply.
- A brain tumour
Triggers
These can trigger primary thunderclap headaches and, in some cases, the secondary ones too (because, although there is an underlying cause, headache may not be one of the symptoms).
- Sexual activity (in which case, the condition is called post-coital thunderclap headache)
- Hard physical activity
- Strenuous exercise
- Constipation, or straining to pass stools
- Head injury
- Psychedelic or recreational drugs
- Sudden exposure to warm or hot water, especially during a shower or bath (hence it is important to start a bath slowly)
- Hard or intense cough
Symptoms
- Strikes suddenly, with severe intensity
- Reaches a peak within 60 seconds
- Feels like the worst headache the person has ever had
- Accompanied by nausea or vomiting
- Altered mental state (confusion)
- Fever
- Seizures
- Numbness, weakness and fainting
- Difficulty speaking
- Change in vision, or vision problems
- Pain that is felt anywhere in the head
- Pain in the head and neck
- Stiffness in the neck
- Photosensitivity, or sensitivity to light
- Loss of consciousness
- Headache that worsens when the person stands up
- Cranial nerve palsies or malfunction of nerves in the head leading to impaired eye movements
Diagnosis
The following imaging tests reveal intricate details of the brain’s vascular system.
- CT scan of the head: These scans take X-rays images of the brain in various angles and sections. These are then combined using a computer to create a full picture of the head and brain. An iodine-based dye may be used to enhance the picture.
- Spinal tap, also called as lumbar puncture: In this, the doctor removes a small quantity of the cerebrospinal fluid and tests the same for signs of bleeding or infection.
- Magnetic Resonance Imaging or MRI: In this, a magnetic field and radio waves are used to capture cross-sectional images of the structures inside the brain and the same combined using a computer to get a detailed picture
- Magnetic Resonance Angiography or MRA: This is an MRI imaging test that focuses on the blood-vessels inside the brain.
- CT Angiography or CTA: This is a CT scan that focuses on blood-vessels inside the brain
- Magnetic Resonance Venography or MRV: This is an MRI imaging test, specifically of the veins inside the brain
Treatment
Primary thunderclap headaches are treated using Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Indocin. Secondary headaches are treated by treating the underlying cause.
- For tears or blockages in blood-vessels: surgery done by a neurosurgeon may be required
- For hypertensions: Medications is the first line of treatment
- For pain in the head and ache, especially when the trigger is known: Painkillers are prescribed
- For subarachnoid haemorrhage: The person is admitted into an ICU, then medications are given to control blood-pressure and seizures. To stop the bleeding, blood-thinning medicines, if the person was taking previously, will be discontinued
- For Ruptured Aneurysm: Surgery is done to repair the aneurysm. The two most common techniques used are surgical clipping and endovascular coiling.
- For RCVS: Treatment is supportive in nature. The primary focus is on managing blood-pressure and the pain due to headache. The person will be advised to avoid all the potential triggers including exercise and sex.
- For Ischemic stroke: Medication that includes tissue plasminogen activator, or tPA, when given within the first few hours of symptoms showing up, can help open up clogged arteries
- For Meningitis: Antibiotics and antivirals are given through an IV, to destroy the pathogens causing the infection.
Thunderclap headaches are a severe type of headache which can be life-threatening if left untreated due to the potential serious underlying causes. This condition requires immediate medical attention and management. Diagnosis involves imaging tests to reveal intricate details of the brain’s vascular system and the treatment strategy depends largely on the underlying cause. Primary thunderclap headaches can be managed with NSAIDs, however, secondary headaches require a more focused treatment plan targeting the cause, which may include medication, surgery, or supportive care. To ensure effective treatment, consult a well-reputed healthcare provider like Kauvery Hospital, which has branches in Chennai, Hosur, Salem, Tirunelveli, and Trichy.
Frequently Asked Questions
What is a thunderclap headache?
A thunderclap headache is a sudden, severe headache that reaches its peak intensity within 60 seconds.
What causes thunderclap headaches?
They can be caused by serious conditions like subarachnoid hemorrhage, cerebral vasoconstriction, aneurysm rupture, or less severe triggers like intense physical activity.
What are the symptoms of a thunderclap headache?
Symptoms include sudden severe headache, nausea, vomiting, altered mental state, seizures, vision changes, and neck stiffness.
How are thunderclap headaches diagnosed?
Diagnosis involves imaging tests like CT scan, MRI, MRA, and lumbar puncture to identify underlying causes.
How are thunderclap headaches treated?
Treatment depends on the cause and may include medications, surgery, or supportive care.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
Chennai Alwarpet – 044 4000 6000 • Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801