Not all headache disorders are the same. An excruciating, sudden-onset headache known as thunderclap headache (TCH) is a medical emergency, very different from more common headache disorders such as migraine and tension headache. If you develop TCH, you should call 911 or immediately go to the closest hospital.
TCH is associated with a variety of causes, ranging from benign to potentially fatal. Urgent evaluation in an emergency setting is needed to quickly identify and treat any underlying condition.
Diagnosing and treating secondary thunderclap headache
When you arrive at the hospital, the medical team will want to confirm or rule out a potentially serious, secondary cause of the TCH. The initial history and examination will focus on red flags that suggest specific secondary causes.
A secondary TCH has an underlying cause, other than the headache itself. For example, neck stiffness or sleepiness may suggest a ruptured brain aneurysm or infection; a drooping eyelid may indicate a tear in the carotid artery (the main artery supplying the brain); seizures or sudden limb weakness may suggest clots in a blood vessel, or bleeding in the brain (hemorrhage). Absence of these signs and symptoms does not definitively rule out these causes, which is why you will likely undergo imaging of the brain and its blood vessels with either computed tomography (CT) or magnetic resonance imaging (MRI). If imaging does not reveal a clear secondary cause, a lumbar puncture, or spinal tap, may be needed.
If a secondary cause is identified, the underlying problem will be treated. For example, if your TCH was caused by a blood clot in an artery, it would be treated with clot-busting medications or the clot would be removed via a catheter-based procedure.
Primary thunderclap headache and RCVS
If no obvious cause is found, TCH is considered “primary,” or “idiopathic.” Primary TCH typically affects young adults. It is commonly associated with physical triggers such as cough, exercise, and sexual activity.
Rarely, people can develop multiple, recurrent TCHs within a span of a few days. In such cases, imaging invariably shows alternating areas of narrowing and dilation (the appearance is described as “a sausage on a string”) of multiple brain arteries. This condition is called reversible cerebral vasoconstriction syndrome, or RCVS. RCVS can also develop in patients with a single TCH.
Approximately 30% to 50% of patients with RCVS go on to develop brain hemorrhage, strokes, and brain swelling. Thus, if you are diagnosed with RCVS, you will likely be admitted to the hospital for a few days of observation. Despite these possible complications, people with RCVS generally do well; the flurry of TCHs usually subsides within days, and the arterial narrowing resolves on its own within a few weeks.
Treating primary thunderclap headache and RCVS
There is no known preventive medication for primary TCH or RCVS. Bed rest is recommended, since exercise, anxiety, and sexual activity can precipitate more TCHs. Laxatives and stool softeners are also recommended, since straining or bearing down can trigger TCH.
The extreme head pain usually settles in a few minutes, but moderate to severe headache can persist for several hours. Common pain relievers such as acetaminophen (Tylenol) and ibuprofen (Advil) may help. Treatment with more potent drugs, such as morphine and other opioids, may be prescribed for prolonged or very severe head pain.
Certain medications should not be used to treat TCH. These include glucocorticoids, triptans, and other anti-migraine medications, which induce narrowing of brain arteries and can worsen the situation. People with RCVS should also avoid certain drugs for several weeks. These include serotonin-enhancing antidepressants (SSRIs and SNRIs), ecstasy, cannabis, and sympathomimetic and amphetamine derivatives such as pseudoephedrine (a common ingredient in many cough-and-cold remedies, exercise stimulants, and diet pills).
Primary TCH can recur intermittently for several years. Recurrence of an episode of RCVS is extremely rare. Most people can resume routine physical activities and gradually increase the intensity of exercise two to four weeks after the sudden-onset headaches subside.
The extreme head pain of primary TCH and RCVS can understandably evoke significant anxiety. But the long-term outcome is nearly always benign.
Below are spiritual recipe for health and wellness: Matthew E. McLaren
Whoever would foster love covers over an offense, but whoever repeats the matter separates close friends. Proverbs 17:9 NIV
Be kind and compassionate to one another, forgiving each other, just as in Christ God forgave you. Ephesians 4:32 NIV
For if you forgive other people when they sin against you, your heavenly Father will also forgive you. Matthew 6:14 NIV
Bear with each other and forgive one another if any of you has a grievance against someone. Forgive as the Lord forgave you. Colossians 3:13 NIV
If my people, who are called by my name, will humble themselves and pray and seek my face and turn from their wicked ways, then I will hear from heaven, and I will forgive their sin and will heal their land.
2 Chronicles 7:14 NIV
Do not judge, and you will not be judged. Do not condemn, and you will not be condemned. Forgive, and you will be forgiven. Luke 6:37 NIV
Who is a God like you, who pardons sin and forgives the transgression of the remnant of his inheritance?
You do not stay angry forever but delight to show mercy. Micah 7:18 NIV
You, Lord, are forgiving and good, abounding in love to all who call to you. Psalm 86:5 NIV
Therefore, my friends, I want you to know that through Jesus the forgiveness of sins is proclaimed to you. Through him everyone who believes is set free from every sin, a justification you were not able to obtain under the law of Moses. Acts 13:38-39 NIV
He is the atoning sacrifice for our sins, and not only for ours but also for the sins of the whole world. 1 John 2:2 NIV
Whoever conceals their sins does not prosper, but the one who confesses and renounces them finds mercy. Proverbs 28:13 NIV
In him we have redemption through his blood, the forgiveness of sins, in accordance with the riches of God’s grace. Ephesians 1:7 NIV
Rend your heart and not your garments. Return to the Lord your God, for he is gracious and compassionate, slow to anger and abounding in love, and he relents from sending calamity. Joel 2:13 NIV
Peter replied, “Repent and be baptized, every one of you, in the name of Jesus Christ for the forgiveness of your sins. And you will receive the gift of the Holy Spirit.” Acts 2:38 NIV
Then I acknowledged my sin to you and did not cover up my iniquity. I said, “I will confess my transgressions to the Lord.” And you forgave the guilt of my sin. Psalm 32:5 NIV
And forgive us our debts, as we also have forgiven our debtors. Matthew 6:12 NIV
Repent, then, and turn to God, so that your sins may be wiped out, that times of refreshing may come from the Lord. Acts 3:19 NIV
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