Sudden Onset Headache: A Prospective Study of Features, Incidence and Causes

Abstract

Sudden onset headache is a common condition that sometimes indicates a life-threatening subarachnoid haemorrhage (SAH) but is mostly harmless. We have performed a prospective study of 137 consecutive patients with this kind of headache (thunderclap headache=TCH). The examination included a CT scan, CSF examination and follow-up of patients with no SAH during the period between 2 days and 12 months after the headache attack. The incidence was 43 per 100 000 inhabitants >18 years of age per year; 11.3% of the patients with TCH had SAH. Findings in other patients indicated cerebral infarction (five), intracerebral haematoma (three), aseptic meningitis (four), cerebral oedema (one) and sinus thrombosis (one). Thus no specific finding indicating the underlying cause of the TCH attack was found in the majority of the patients. A slightly increased prevalence of migraine was found in the non-SAH patients (28%). The attacks occurred in 11 cases (8%) during sexual activity and two of these had an SAH. Nausea, neck stiffness, occipital location and impaired consciousness were significantly more frequent with SAH but did not occur in all cases. Location in the temporal region and pressing headache quality were the only features that were more common in non-SAH patients. Recurrent attacks of TCH occurred in 24% of the non-SAH patients. No SAH occurred later in this group, nor in any of the other patients. It was concluded that attacks caused by a SAH cannot be distinguished from non-SAH attacks on clinical grounds. It is important that patients with their first TCH attack are investigated with CT and CSF examination to exclude SAH, meningitis or cerebral infarction. The results from this and previous studies indicate that it is not necessary to perform angiography in patients with a TCH attack, provided that no symptoms or signs indicate a possible brain lesion and a CT scan and CSF examination have not indicated SAH.

Late presentation of primary headache associated with sexual activity: is non-invasive angiography worthwhile?

“…Catheter angiography was negative in all nine patients examined in the study by Lance [5]. In a cohort of 137 patients with sudden onset headache, in 11 (8%) onset was during sex, only 2 of whom had SAH [6].…”

The management of the patient with headache: from evidence to clinical practice

“…45 In fact many systematic reviews and observational studies have demonstrated that about 70% of ESA is characterized by a thunderclap pattern. 46 However ESA is misidentified in 1/3 of patients, in particular in those that have only headache and have a normal Glasgow coma score. ESA is caused in 85% of cases by the breakage of a cerebral artery aneurysm.…”

“…For example 90% of patients with temporal arteritis and with subarachnoid hemorrhage have headache. 46 Clinical manifestation can be completely unspecific and may be similar to clinical presentation of migraine or tension-type headache. Red flags for secondary disorders 1 as reported in Table 3 1 include new or change in headache after 50 years of age, increased frequency or severity of headache, new onset of headache with an underlying medical condition, headache with concomitant systemic illness, focal neurologic signs or symptoms, papilledema and headache subsequent to head trauma.…”

“…A secondary headache disorders may be identified with the presence of diplopia, stiff neck, rash, fever, eye pain, unilateral paresthesias, disorientation and balance change. 46 Differential diagnosis includes meningitis, subarachnoid hemorrhage, epidural or subdural hematoma, glaucoma, tumor, and purulent sinusitis. Finally it is important to assess any recent head trauma or dental procedure as well as any medications taken by the patient (especially caffeine-containing analgesics).…”

“…Headache features that often warrant neuroimaging includes: isolated thunderclap headache, headache radiating to the neck, temporal headache in an older individual, headaches with increasing frequency or severity and headaches not responding to the treatment. 46 New headache in HIV positive, in pregnancy, in patient older than 50 years of age or with a history of cancer required further investigations. Abnormality of neurological examination is the most predictor of intracranial pathologic conditions on subsequent imaging.…”