Clinical presentation

Patients with a first presentation of thunderclap headache should be referred immediately to hospital for same day specialist assessment (1,2).

A detailed history should be obtained to recognize thunderclap headache.

• the rapidity with which the TCH reached it's peak and what the maximum severity was on an 11 point scale - 0 no pain; 1-3 mild pain; 4-6 moderate pain; 7-9 severe pain; 10 worst pain ever
  • a headache that reaches 7 or more within less than one minute is considered to be a thunderclap headache
    
    
• the pain maybe localized to 1 region or maybe holocephalic
  
  
• TCH maybe accompanied by several other symptoms which may indicate the underlying cause
  • neck stiffness: subarachnoid haemorrhage or meningitis
  • transient loss of consciousness: subarachnoid haemorrhage (around 50% of cases), colloid cyst of the third ventricle
  • epileptic seizure: subarachnoid haemorrhage ,other stroke, cerebral venous thrombosis, posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS)
  • focal neurological symptoms: subarachnoid haemorrhage, other stroke, cerebral venous thrombosis
  • papilloedema: intracranial hypertension

Reference:

1. SIGN (March 2008).Diagnosis and Management of headaches in adult.
2. NICE. Headaches in over 12s: diagnosis and management. Clinical guideline CG150. Published September 2012, last updated December 2021