Intended for healthcare professionals

Clinical Review

Thunderclap headache

BMJ 2013; 346 doi: (Published 09 January 2013) Cite this as: BMJ 2013;346:e8557
  1. Anne Ducros, neurologist1,
  2. Marie-Germaine Bousser, professor of neurology2
  1. 1Emergency Headache Centre, Head and Neck Clinic, Lariboisière Hospital, Assistance Publique Hôpitaux de Paris, 75010 Paris, France
  2. 2Neurology Department, Head and Neck Clinic, Lariboisière Hospital
  1. Correspondence to: A Ducros anne.ducros{at}

Summary points

  • Thunderclap headache is a severe headache that peaks within 60 seconds of onset

  • Neurovascular disorders often present with thunderclap headache

  • Infectious disorders, intracranial hypertension, and hypotension syndromes occasionally present with thunderclap headache

  • Subarachnoid haemorrhage is the most common cause; diagnosis is based on plain brain computed tomography (CT) and, if normal, on lumbar puncture

  • Suspect reversible cerebral vasoconstriction syndrome when thunderclap headaches recur over a few days

  • Cervical artery dissection, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome, and pituitary apoplexy may present with isolated thunderclap headache and normal physical examination, CT, and cerebrospinal fluid

  • When CT and cerebrospinal fluid are normal, other investigations are needed, including cervical and cerebral vascular imaging and brain magnetic resonance imaging

Headache affects about 90% of the general population. The most common causes are migraine and episodic tension-type headache. A small proportion of patients present acutely to a primary care doctor, and the main objective is to identify those who require urgent investigations.

The term thunderclap headache is used to decribe a severe headache of instantaneous onset—one minute at the most.1 Estimated incidence is about 43 per 100 000 adults per year in the developed world.2 In our emergency headache centre, out of a total of 8000 patients each year, about 120 present with thunderclap headache. Any thunderclap headache, even in a patient with a history of recurrent headache, such as migraine, must be considered as secondary to a variety of causes, the foremost of which is subarachnoid haemorrhage.3 4 Making a diagnosis can be challenging. Even when brain computed tomography (CT) and lumbar puncture results are normal, the underlying cause can be serious—for example, cervical artery dissection, cerebral venous thrombosis, and reversible cerebral vasoconstriction syndrome (RCVS).4 5

This review aims to describe the various causes of thunderclap headache and the role …

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