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Thunderclap headache

Todd J Schwedt, MD, MSCI
David W Dodick, MD
Section Editor
Jerry W Swanson, MD, MHPE
Deputy Editor
John F Dashe, MD, PhD


Thunderclap headache (TCH) refers to a severe headache of sudden onset. Its explosive and unexpected nature is likened to a "clap of thunder." Although TCH initially referred to pain associated with an unruptured intracranial aneurysm [1], multiple etiologies are now recognized [2] (table 1). These include cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, ischemic stroke, acute hypertensive crisis with reversible posterior leukoencephalopathy syndrome, third ventricular colloid cysts, bacterial and viral meningitis, complicated sinusitis, and reversible cerebral vasoconstriction syndromes.

In addition, the term primary TCH is often used to refer to a benign, idiopathic, and potentially recurrent headache of sudden and severe intensity with a lack of underlying pathology.

This topic will review each of the entities considered in patients with TCH, offer pathophysiologic considerations, and discuss the diagnostic evaluation of TCH.


In addition to the pain associated with the onset of subarachnoid hemorrhage from intracranial aneurysm rupture, thunderclap headache may be associated with multiple other causes (table 1).

Reversible cerebral vasoconstriction syndromes


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Literature review current through: Jun 2017. | This topic last updated: Dec 10, 2014.
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  1. Day JW, Raskin NH. Thunderclap headache: symptom of unruptured cerebral aneurysm. Lancet 1986; 2:1247.
  2. Ducros A, Bousser MG. Thunderclap headache. BMJ 2013; 346:e8557.
  3. Broner S, Lay C, Newman L, Swerdlow M. Thunderclap headache as the presenting symptom of myocardial infarction. Headache 2007; 47:724.
  4. Evans RW. Thunderclap headache associated with a nonhemorrhagic anaplastic oligodendroglioma. MedGenMed 2007; 9:26.
  5. Mucchiut M, Valentinis L, Tuniz F, et al. Adult aqueductal stenosis presenting as a thunderclap headache: a case report. Cephalalgia 2007; 27:1171.
  6. Heo YE, Kwon HM, Nam HW. Thunderclap headache as an initial manifestation of phaeochromocytoma. Cephalalgia 2009; 29:388.
  7. Im SH, Kim NH. Thunderclap headache after micturition in bladder pheochromocytoma. Headache 2008; 48:965.
  8. Cho JH, Ahn JY, Byeon SH, Huh JS. Thunderclap headache as initial manifestation of Vogt-Koyanagi-Harada disease. Headache 2008; 48:153.
  9. Landtblom AM, Fridriksson S, Boivie J, et al. Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia 2002; 22:354.
  10. Markus HS. A prospective follow up of thunderclap headache mimicking subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1991; 54:1117.
  11. Linn FH, Rinkel GJ, Algra A, van Gijn J. Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 1998; 65:791.
  12. Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000; 342:29.
  13. Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 2004; 291:866.
  14. Polmear A. Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review. Cephalalgia 2003; 23:935.
  15. Calabrese LH, Dodick DW, Schwedt TJ, Singhal AB. Narrative review: reversible cerebral vasoconstriction syndromes. Ann Intern Med 2007; 146:34.
  16. Ducros A. Reversible cerebral vasoconstriction syndrome. Lancet Neurol 2012; 11:906.
  17. Dodick DW, Brown RD Jr, Britton JW, Huston J 3rd. Nonaneurysmal thunderclap headache with diffuse, multifocal, segmental, and reversible vasospasm. Cephalalgia 1999; 19:118.
  18. Slivka A, Philbrook B. Clinical and angiographic features of thunderclap headache. Headache 1995; 35:1.
  19. Calabrese LH, Gragg LA, Furlan AJ. Benign angiopathy: a distinct subset of angiographically defined primary angiitis of the central nervous system. J Rheumatol 1993; 20:2046.
  20. Hajj-Ali RA, Furlan A, Abou-Chebel A, Calabrese LH. Benign angiopathy of the central nervous system: cohort of 16 patients with clinical course and long-term followup. Arthritis Rheum 2002; 47:662.
  21. Call GK, Fleming MC, Sealfon S, et al. Reversible cerebral segmental vasoconstriction. Stroke 1988; 19:1159.
  23. Schluter A, Kissig B. MR angiography in migrainous vasospasm. Neurology 2002; 59:1772.
  24. Farine D, Andreyko J, Lysikiewicz A, et al. Isolated angiitis of brain in pregnancy and puerperium. Obstet Gynecol 1984; 63:586.
  25. Janssens E, Hommel M, Mounier-Vehier F, et al. Postpartum cerebral angiopathy possibly due to bromocriptine therapy. Stroke 1995; 26:128.
  26. Henry PY, Larre P, Aupy M, et al. Reversible cerebral arteriopathy associated with the administration of ergot derivatives. Cephalalgia 1984; 4:171.
  27. Meschia JF, Malkoff MD, Biller J. Reversible segmental cerebral arterial vasospasm and cerebral infarction: possible association with excessive use of sumatriptan and Midrin. Arch Neurol 1998; 55:712.
  28. Singhal AB, Caviness VS, Begleiter AF, et al. Cerebral vasoconstriction and stroke after use of serotonergic drugs. Neurology 2002; 58:130.
  29. Levine SR, Washington JM, Jefferson MF, et al. "Crack" cocaine-associated stroke. Neurology 1987; 37:1849.
  30. Reneman L, Habraken JB, Majoie CB, et al. MDMA ("Ecstasy") and its association with cerebrovascular accidents: preliminary findings. AJNR Am J Neuroradiol 2000; 21:1001.
  31. Ducros A, Boukobza M, Porcher R, et al. The clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome. A prospective series of 67 patients. Brain 2007; 130:3091.
  32. Singhal AB, Hajj-Ali RA, Topcuoglu MA, et al. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol 2011; 68:1005.
  33. Ducros A, Fiedler U, Porcher R, et al. Hemorrhagic manifestations of reversible cerebral vasoconstriction syndrome: frequency, features, and risk factors. Stroke 2010; 41:2505.
  34. Sturm JW, Macdonell RA. Recurrent thunderclap headache associated with reversible intracerebral vasospasm causing stroke. Cephalalgia 2000; 20:132.
  35. Nowak DA, Rodiek SO, Henneken S, et al. Reversible segmental cerebral vasoconstriction (Call-Fleming syndrome): are calcium channel inhibitors a potential treatment option? Cephalalgia 2003; 23:218.
  36. Dodick DW. Reversible segmental cerebral vasoconstriction (Call-Fleming syndrome): the role of calcium antagonists. Cephalalgia 2003; 23:163.
  37. Lu SR, Liao YC, Fuh JL, et al. Nimodipine for treatment of primary thunderclap headache. Neurology 2004; 62:1414.
  38. Chen SP, Fuh JL, Lirng JF, et al. Recurrent primary thunderclap headache and benign CNS angiopathy: spectra of the same disorder? Neurology 2006; 67:2164.
  39. Linn J, Fesl G, Ottomeyer C, et al. Intra-arterial application of nimodipine in reversible cerebral vasoconstriction syndrome: a diagnostic tool in select cases? Cephalalgia 2011; 31:1074.
  40. de Bruijn SF, Stam J, Kappelle LJ. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group. Lancet 1996; 348:1623.
  41. Cumurciuc R, Crassard I, Sarov M, et al. Headache as the only neurological sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry 2005; 76:1084.
  42. Rao KC, Knipp HC, Wagner EJ. Computed tomographic findings in cerebral sinus and venous thrombosis. Radiology 1981; 140:391.
  43. Chiras J, Bousser MG, Meder JF, et al. CT in cerebral thrombophlebitis. Neuroradiology 1985; 27:145.
  44. Mitsias P, Ramadan NM. Headache in ischemic cerebrovascular disease. Part I: Clinical features. Cephalalgia 1992; 12:269.
  45. Maruyama H, Nagoya H, Kato Y, et al. Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only symptom. J Headache Pain 2012; 13:247.
  46. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
  47. Rando TA, Fishman RA. Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology 1992; 42:481.
  48. Schievink WI, Wijdicks EF, Meyer FB, Sonntag VK. Spontaneous intracranial hypotension mimicking aneurysmal subarachnoid hemorrhage. Neurosurgery 2001; 48:513.
  49. Dodick DW, Wijdicks EF. Pituitary apoplexy presenting as a thunderclap headache. Neurology 1998; 50:1510.
  50. Embil JM, Kramer M, Kinnear S, Light RB. A blinding headache. Lancet 1997; 350:182.
  51. Schievink WI, Thompson RC, Loh CT, Maya MM. Spontaneous retroclival hematoma presenting as a thunderclap headache. Case report. J Neurosurg 2001; 95:522.
  52. Ferro JM, Melo TP, Oliveira V, et al. A multivariate study of headache associated with ischemic stroke. Headache 1995; 35:315.
  53. Vestergaard K, Andersen G, Nielsen MI, Jensen TS. Headache in stroke. Stroke 1993; 24:1621.
  54. Schwedt TJ, Dodick DW. Thunderclap stroke: embolic cerebellar infarcts presenting as thunderclap headache. Headache 2006; 46:520.
  55. Edvardsson BA, Persson S. Cerebral infarct presenting with thunderclap headache. J Headache Pain 2009; 10:207.
  56. Gossrau G, Dannenberg C, Reichmann H, Sabatowski R. [Thunderclap headache caused by cerebellar infarction]. Schmerz 2008; 22:82.
  57. Tang-Wai DF, Phan TG, Wijdicks EF. Hypertensive encephalopathy presenting with thunderclap headache. Headache 2001; 41:198.
  58. Dodick DW, Eross EJ, Drazkowski JF, Ingall TJ. Thunderclap headache associated with reversible vasospasm and posterior leukoencephalopathy syndrome. Cephalalgia 2003; 23:994.
  59. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996; 27:144.
  60. Healton EB, Brust JC, Feinfeld DA, Thomson GE. Hypertensive encephalopathy and the neurologic manifestations of malignant hypertension. Neurology 1982; 32:127.
  61. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996; 334:494.
  62. Schwartz RB, Jones KM, Kalina P, et al. Hypertensive encephalopathy: findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol 1992; 159:379.
  63. Schwartz RB, Mulkern RV, Gudbjartsson H, Jolesz F. Diffusion-weighted MR imaging in hypertensive encephalopathy: clues to pathogenesis. AJNR Am J Neuroradiol 1998; 19:859.
  64. KELLY R. Colloid cysts of the third ventricle; analysis of twenty-nine cases. Brain 1951; 74:23.
  65. Michels LG, Rutz D. Colloid cysts of the third ventricle. A radiologic-pathologic correlation. Arch Neurol 1982; 39:640.
  66. Young WB, Silberstein SD. Paroxysmal headache caused by colloid cyst of the third ventricle: case report and review of the literature. Headache 1997; 37:15.
  67. Linn FH, Wijdicks EF, van der Graaf Y, et al. Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet 1994; 344:590.
  68. McGeeney BE, Barest G, Grillone G. Thunderclap headache from complicated sinusitis. Headache 2006; 46:517.
  69. Linn FH. Primary thunderclap headache. Handb Clin Neurol 2010; 97:473.
  70. ARMSTRONG FS, HAYES GJ. Segmental cerebral arterial constriction associated with pheochromocytoma: report of a case with arteriograms. J Neurosurg 1961; 18:843.
  71. Trommer BL, Homer D, Mikhael MA. Cerebral vasospasm and eclampsia. Stroke 1988; 19:326.
  72. Margolis MT, Newton TH. Methamphetamine ("speed") arteritis. Neuroradiology 1971; 2:179.
  73. Kaye BR, Fainstat M. Cerebral vasculitis associated with cocaine abuse. JAMA 1987; 258:2104.
  74. Furlan JC. Headache attributed to autonomic dysreflexia: an underrecognized clinical entity. Neurology 2011; 77:792.
  75. Edvinsson L, Gulbenkian S, Barroso CP, et al. Innervation of the human middle meningeal artery: immunohistochemistry, ultrastructure, and role of endothelium for vasomotility. Peptides 1998; 19:1213.
  76. Edvinsson L, Owman C. Cerebrovascular nerves and vasomotor receptors. In: Cerebral arterial spasm, Wilkins RH (Ed), Williams and Wilkins, Baltimore 1980. p.30.
  77. Endo S, Suzuki J. Experimental cerebral vasospasm after subarachnoid hemorrhage. Participation of adrenergic nerves in cerebral vessel wall. Stroke 1979; 10:703.
  78. Edvinsson L, Egund N, Owman C, et al. Reduced noradrenaline uptake and retention in cerebrovascular nerves associated with angiographically visible vasoconstriction following experimental subarachnoid hemorrhage in rabbits. Brain Res Bull 1982; 9:799.
  79. van Gijn J, van Dongen KJ. The time course of aneurysmal haemorrhage on computed tomograms. Neuroradiology 1982; 23:153.
  80. Vermeulen M, Hasan D, Blijenberg BG, et al. Xanthochromia after subarachnoid haemorrhage needs no revisitation. J Neurol Neurosurg Psychiatry 1989; 52:826.
  81. Moussouttas M, Mayer SA. Thunderclap headache with normal CT and lumbar puncture: further investigations are unnecessary: against. Stroke 2008; 39:1394.
  82. Davis SM, Donnan GA. Thunderclap headache: CT and lumbar puncture but occasionally more! Stroke 2008; 39:1396.
  83. Savitz SI, Levitan EB, Wears R, Edlow JA. Pooled analysis of patients with thunderclap headache evaluated by CT and LP: is angiography necessary in patients with negative evaluations? J Neurol Sci 2009; 276:123.
  84. Wijdicks EF, Kerkhoff H, van Gijn J. Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid haemorrhage. Lancet 1988; 2:68.
  85. Linn FH, Rinkel GJ, Algra A, van Gijn J. Follow-up of idiopathic thunderclap headache in general practice. J Neurol 1999; 246:946.
  86. Harling DW, Peatfield RC, Van Hille PT, Abbott RJ. Thunderclap headache: is it migraine? Cephalalgia 1989; 9:87.
  87. Landtblom, AM, Boivie, J, Fridriksson, S, et al. Thunderclap headache: final results from a prospective study of consecutive cases. Acta Neurol Scand 1996; 167 (Suppl 94):23.
  88. RAYNOR RB, ROSS G. Arteriography and vasospasm. The effects of intracarotid contrast media on vasospasm. J Neurosurg 1960; 17:1055.
  89. Warnock NG, Gandhi MR, Bergvall U, Powell T. Complications of intraarterial digital subtraction angiography in patients investigated for cerebral vascular disease. Br J Radiol 1993; 66:855.
  90. Wardlaw JM, White PM. The detection and management of unruptured intracranial aneurysms. Brain 2000; 123 ( Pt 2):205.
  91. Alberico RA, Patel M, Casey S, et al. Evaluation of the circle of Willis with three-dimensional CT angiography in patients with suspected intracranial aneurysms. AJNR Am J Neuroradiol 1995; 16:1571.
  92. Hope JK, Wilson JL, Thomson FJ. Three-dimensional CT angiography in the detection and characterization of intracranial berry aneurysms. AJNR Am J Neuroradiol 1996; 17:439.
  93. Schwedt TJ. Clinical spectrum of thunderclap headache. Expert Rev Neurother 2007; 7:1135.