Re: Thunderclap headache
Ducros et al provided a comprehensive review of the investigation and management of thunderclap headache . We would suggest that an ECG be added to the list of mandatory investigations in such patients.
It is well known that primary intra-cranial pathology such as sub-arachnoid haemorrhage can cause ECG changes and cardiac enzyme release. However, myocardial ischaemia presenting with headache is less well recognised. We and others have reported the extremely rare scenario of thunderclap headache as the sole presenting symptom of acute ST-elevation myocardial infarction [2-4]. Although rare, a simple ECG would allow the identification of such patients who, following prompt exclusion of intra-cranial pathology, can be urgently referred to cardiology for consideration of optimal reperfusion therapy.
 Ducros A, Bousser MG. Thunderclap headache. BMJ. 2013;346:e8557.
 Broner S, Lay C, Newman L, Swerdlow M. Thunderclap headache as the presenting symptom of myocardial infarction. Headache. 2007;47:724-5.
 Seow VK, Chong CF, Wang TL, Ong JR. Severe explosive headache: a sole presentation of acute myocardial infarction in a young man. Am J Emerg Med. 2007;25:250-1.
 Dalzell JR, Jackson CE, Robertson KE, McEntegart MB, Hogg KJ. A case of the heart ruling the head: acute myocardial infarction presenting with thunderclap headache. Resuscitation. 2009;80:608-9.