Abrupt-Onset Severe Headaches

Semin Neurol 2010; 30(2): 192-200 DOI: 10.1055/s-0030-1249229

© Thieme Medical Publishers

Yo-El S. Ju1, Todd J. Schwedt1

1 Department of Neurology, Washington University School of Medicine, St. Louis, Missouri

ABSTRACT

Thunderclap headache, a severe headache which is maximal in intensity at onset, is associated with numerous underlying disorders, including

1. subarachnoid hemorrhage, 
2. unruptured intracranial aneurysm, 
3. cervical artery dissection, 
4. cerebral venous sinus thrombosis, 
5. stroke, 
6. intracranial hemorrhage, 
7. reversible cerebral vasoconstriction syndrome, and 
8. reversible posterior leukoencephalopathy. 

After exclusion of all possible causes, thunderclap headache may be considered a primary headache.

This review summarizes the diagnostic considerations and clinical approach to thunderclap headache, with particular emphasis on the reversible cerebral vasoconstriction syndromes.

Headache, cardiac arrest, and intracranial hemorrhage

The Journal of Headache and Pain Volume 10, Number 5 / October, 2009
Joji Inamasu1, 2 , Satoru Miyatake1, Hideto Tomioka1, Masashi Nakatsukasa2, Akira Imai3, Kenichi Kase1 and Kenji Kobayashi1

(1) Department of Emergency Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya Tochigi, 321-0974, Japan
(2) Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
(3) Department of Neurology, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan

Received: 20 April 2009 Accepted: 17 June 2009 Published online: 14 July 2009

Abstract Headache is one of the most common manifestations of non-traumatic intracranial hemorrhage, which is an uncommon, but not rare, cause of cardiac arrest in adults. History of a sudden headache preceding collapse may be a helpful clue to estimate the cause of out-of-hospital cardiac arrest (OHCA). Medical records of witnessed OHCA patients were reviewed to identify those who complained of a sudden headache preceding collapse, and the incidence of intracranial hemorrhage among them as well as their clinical characteristics was investigated retrospectively. During the 12-month period, 124 patients who sustained a witnessed OHCA were treated. Among them, 74 (60%) collapsed without any pain complaint, and only 6 (5%) complained of a sudden headache preceding collapse. All of the six patients were resuscitated: four had a severe subarachnoid hemorrhage (SAH), while the other two had a massive cerebellar hemorrhage. By contrast, 39 of the 74 patients who collapsed without any pain were resuscitated. Among them, another six patients were found to harbor an SAH. Thus, a total of 12 among the 124 witnessed OHCA (10%) sustained a fatal intracranial hemorrhage. While OHCA patients who collapse complaining of a sudden headache are uncommonly seen in the emergency room, they have a high likelihood of harboring a severe intracranial hemorrhage. It should also be reminded that approximately half of patients whose cardiac arrest is due to an intracranial hemorrhage may collapse without complaining of a headache. The prognosis of those with cerebral origin of OHCA is invariably poor, although they may relatively easily be resuscitated temporarily. Focus needs to be directed to avoid sudden death from a potentially treatable cerebral lesion, and public education to promote the awareness for the symptoms of potentially lethal hemorrhagic stroke is warranted.

Joji Inamasu
Email: ginamasu@aol.com