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Clinical Review

Thunderclap headache

BMJ 2013; 346 doi: (Published 09 January 2013) Cite this as: BMJ 2013;346:e8557

Rapid Response:

Re: Thunderclap headache

This is an excellent review of the management of patients presenting with thunderclap headache. However, I feel that it could be misleading with regards to the management of the acute severe headache in the neurologically intact patient. The article defines thunderclap headache as a severe headache that peaks within 60 seconds of onset. Although this is an acceptable definition it is important to be aware that with traditional diagnoses associated with thunderclap headache it can take longer than this for maximal intensity of pain to be reached.

Perry et al recruited 1999 patients with acute headache defined as peak onset within an hour or associated with syncope. Within this population there were 130 cases of subarachnoid haemorrhage and 48 other causes of secondary headache. A ‘severe headache’ was not part of the inclusion criteria, most patients presenting to an unscheduled care setting with a chief complaint of headache will consider their headache to be severe.

Although I appreciate that this article is focused on the thunderclap headache, patients presenting with an acute headache peaking within an hour or associated with syncope should be considered to have a secondary cause.

High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
Jeffrey J Perry, Ian G Stiell, Marco L A Sivilotti, Michael J Bullard, Jacques S Lee, Mary Eisenhauer, Cheryl Symington, Melodie Mortensen, Jane Sutherland, Howard Lesiuk, George A Wells
BMJ 2010;341:c5204 (Published 28 October 2010)

Competing interests: No competing interests

15 January 2013
David Hodgson
Emergency Medicine Registrar
Macclesfield District General Hospital
Victoria Road, Macclesfield, Cheshire SK10 3BL