Focus on the management of thunderclap headache: from nosography to treatment

Ferrante, E.; Tassorelli, Cristina; Rossi, P.; Lisotto, C.; Nappi, G.

doi:10.1007/s10194-011-0302-z

The Journal of Headache and Pain

Table 2 Differential diagnosis of TCH

From: Focus on the management of thunderclap headache: from nosography to treatment

Disease	Neurological symptoms/signs	Precipitating factors	Comments
Subarachnoid haemorrhage (SAH) [19–32]	Headache	Physical exertion	About 70% of pts with SAH present with headache alone
	Loss of consciousness	Sexual intercourse
	Focal neurological symptoms	Sexual intercourse
Cerebral venous sinus thrombosis (CVST) [33–42]	Headache	Puerperium	15–30% of pts present with isolated headache that can worsen in the recumbent position
	Altered consciousness	Dehydration
	Focal neurological symptoms/signs	Cancer
Cervical artery dissection (CAD) [3, 43–45]	Headache	Head and neck injury	Generally headache is ipsilateral to the CAD
	Amaurosis fugax
	Horner’s syndrome
	Focal neurological symptoms/signs
Acute hypertensive crisis (AHC) [46–51]	Headache	Hypertensive crisis	Headache occurs in about 20% of pts with AHC
	Altered mental status	Hypertensive crisis	Headache occurs in about 20% of pts with AHC
	Seizures
	Focal neurological symptoms/signs
Spontaneous retroclival hematoma (SRH) [52, 53]	Headache	None	SRH is very rare
	Mild nuchal rigidity
	Oculomotor nerve palsy
	Upper limb paresis
Sentinel headache (SH) [54]	Headache	Physical exertion	SH is present in 10–40% of pts with SAH
Sentinel headache (SH) [54]	Focal neurological symptoms/signs generally absent	Sexual intercourse	SH is present in 10–40% of pts with SAH
Ischaemic stroke (IS) [55–58]	Headache	None	Headache is more common with large IS
Ischaemic stroke (IS) [55–58]	Focal neurological symptoms/signs	None	Headache is more common with large IS
Pituitary apoplexy (PA) [22, 58–60]	Headache	Pregnancy	PA commonly occurs in pts with no known pituitary tumour history
Pituitary apoplexy (PA) [22, 58–60]	Visual disturbances	Pregnancy
Spontaneous intracranial hypotension (SIH) [61–64]	Orthostatic headache	Valsalva manoeuvre	TCH is present, at onset, in about 15% of pts with SIH
	Hearing disturbances
	Mild nuchal rigidity
Colloid cysts of third ventricle [73–75]	Headache	None	Headache can be relieved by recumbency
	Loss of consciousness
	Seizures
	Coma
Reversible cerebral vasoconstriction syndrome (RCVS) [8, 69–73]	Headache	Postpartum	RCVS is spontaneous in about 30% of cases
	Focal neurological symptoms/signs	Sexual intercourse	RCVS is spontaneous in about 30% of cases
		Drugs exposure (see bottom of table)	Prognosis is uncertain, but most pts do well
		Blood products (see bottom of table)
		Head trauma
		Neurosurgical procedures
Benign hot bath-related headache [74–78]	Headache	Hot bath	Headache disappears spontaneously after a period of 2 weeks to 3 months
Benign hot bath-related headache [74–78]	Normal neurological examination	Hot shower
Primary cough,	Headache	Cough	These headache forms are
sexual and exertional headaches [3, 79]	Normal neurological examination	Physical exertion	an exclusion diagnosis
sexual and exertional headaches [3, 79]	Normal neurological examination	Sexual activity	an exclusion diagnosis
Primary angiitis of the central nervous system (PACNS) [72, 80–83]	Headache	None	Headache is the most common presenting symptom
	Seizures
	Behavioural disturbances
	Focal neurological symptoms/signs
Primary thunderclap headache (TCH) [3, 12–15, 24, 26, 84–89]	Headache	None	TCH is an exclusion diagnosis and has a relatively benign prognosis
	Normal neurological examination	None

Drugs exposure phenylpropanolamine, ergotamine tartrate, methergine, bromocryptine, lisuride, tricyclic antidepressants, selective serotonin reuptake inhibitors, sumatriptan, isometheptine, cocaine, ecstasy, amphetamine derivatives, marijuana, lysergic acid diethylamide, tacrolimus (FK-506), cyclophosphamide
Blood products erythropoietin, intravenous immune globulin, and red blood cell transfusions

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ISSN: 1129-2377

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