Secondary causes of thunderclap headache

Secondary causes of thunderclap headaches include (1,2):

An underlying cause should be considered in any patient with thunderclap headache even with a history of recurrent headaches (such as migraine).

• subarachnoid haemorrhage
  • most common cause
  • around 50% of patients presents with thunderclap pattern of headache
  • subarachnoid haemorrhage is found in 11-25% of patients who present with thunderclap headache (1)
  • be aware that 4-8% of patients with subarachnoid haemorrhage might present without headache at onset (3)
  • if possible subarachnoid haemorrhage then consider other associated clinical features including (3):
    • focal neurological symptoms (cranial nerve, speech, motor, sensory, or coordination deficits),
    • meningism (nuchal rigidity with neck flexion), and
    • an altered level of consciousness
      
• sentinel headache
• reversible cerebral vasoconstriction syndrome
• cerebral venous sinus thrombosis
• cervical artery dissection
• acute angle closure glaucoma
  • clinical presentation is characterised by (3):
    • sudden unilateral headache, associated with decreased visual acuity, eye pain, photophobia, and a mid-dilated pupil
    • pain associated with acute angle closure glaucoma can be abrupt in onset and generalised in nature
      • some patients present with complaint of features of a unilateral thunderclap headache
• spontaneous intracranial hypotension
• acute hypertensive crisis
• intracerebral haemorrhage
• pituitary apoplexy
• brain infarct
• hydrocephalus (aqueductal stenosis, Chiari type 1 malformation)
• tumour (third ventricle colloid cyst, posterior fossa tumour)
• ischemic stroke
• primary cough, sexual, and exertional headache
• myocardial infarction
• pheochromocytoma

Reference:

1. Ducros A, Bousser MG. Thunderclap headache. BMJ. 2013;346:e8557
2. Tarshish S, Robbins MS. Teaching case presentation--primary thunderclap headache. Headache. 2009;49(8):1249-50
3. Rosenberg H, Lin K Y, Jin A Y, Perry J J. Assessment and investigation of thunderclap headacheBMJ 2025; 389 :2024-083247