Headache Medicine, v.10, n.4, p.189-192, Out/Nov/Dez. 2019
Descritores: Aneurisma Roto. Cefaleias Vasculares. Hemorragia Subaracnóidea.
Prevalence of thunderclap headache in patients with
ruptured intracranial aneurysms: series of 60 cases
Prevalência de cefaleia thunderclap em pacientes
com aneurisma intracraniano roto: série de 60
Bruno Bertoli Esmanhotto
Elcio Juliato Piovesan
Marcos Christiano Lange
Faculdades Pequeno Príncipe, Curso de
Medicina - Curitiba - PARANA - Brasil.
Hospital de Clínicas - Universidade Federal
do Paraná, Departamento de Neurologia -
Bruno Bertoli Esmanhotto
E-mail: bbesmanhotto@hotmail.com
Received: December 19, 2019.
Accepted: December 30, 2019.
Thunderclap headache (TCH) is a head pain that begins suddenly and is severe
at onset. TCH might be the rst sign of subarachnoid hemorrhage. This study
was conducted to evaluate the presence of thunderclap headache (TCH) in
patients with ruptured intracranial aneurysm (RIA) and endovascular treatment
(EVT). We evaluated the pattern of headache in 60 patients who suffered a RIA
and EVT at time of admission and prospectively evaluated the characteristics
of previous headache within one year before the rupture. Thirty-one patients
(51,7 %) had TCH related to the rupture. Aneurysm size does not affect the
occurrence of thunderclap headache (p=0,08). The vascular aneurysm territory
is not related to presence of TCH (p=0,527). The prevalence of TCH in this cohort
was similar to previous studies. All patients with acute thunderclap headache
should be evaluated for subarachnoid hemorrhage.
Keywords: Ruptured Aneurysm; Subarachnoid Hemorrhage; Vascular Headache.
Cefaleia thunderclap (CT) é uma dor de cabeça de início súbito e muito intensa.
Pode ser o primeiro sinal de uma hemorragia subaracnoídea (HAS). Este estudo
foi realizado para avaliar a prevalência de cefaleia thunderclap em pacientes que
sofreram ruptura de aneurisma intracraniano (RIA) e submetidos a tratamento
endovascular.(TEV) Foram avaliados 60 participantes com quadro de RIA e TEV
no momento da admissão hospitalar, e foi questionado sobre as características
da dor de cabeça prévia por um ano antes da ruptura. Trinta e um (51,7%) dos
participantes relataram CT no momento da ruptura. O tamanho do aneurisma
não teve relação com a ocorrência da CT (p=0.08). O território vascular também
não teve relação com a presença de CT (p=0,527). A prevalência de CT neste
estudo foi semelhante ao relatado em estudos prévios. Todos os pacientes com
CT devem ser investigados para hemorragia subaracnoídea.
Thunderclap Headache In Ruptured Aneurysm
Esmanhotto BB, et al.
Headache Medicine, v.10, n.4, p.189-192, Out/Nov/Dez. 2019
One of the main symptoms in patients with an
intracranial aneurysm is headache, which is observed
in all stages of the disease, i.e., prior to, during and
after rupture of the aneurysm. Headache may be the
only presenting symptom in up to 40% of patients
Multicenter studies have shown that in the period before
rupture headache is present in up to 36% of cases
The character of the headache is not very specic,
and there is no single pain characteristic that allows a
diagnosis of aneurysm
to be suspected other than the
presence of thunderclap headache (TCH), which requires
investigation for subarachnoid hemorrhage
Subarachnoid hemorrhage is most commonly
due to rupture of an intracranial aneurysm. Ruptured
aneurysms account for 85% of cases, non-aneurysmal peri
mesencephalic hemorrhage (with excellent prognosis)
account for 10%, and various rare disorders (transmural
arterial dissection, cerebral arteriovenous malformation,
dural arteriovenous stula, mycotic aneurysm, and
cocaine abuse) account for the rest
‘‘Thunderclap headache’’ refers to a headache that
is very severe and has abrupt onset, reaching maximum
intensity in less than 1 minute. A thunderclap headache
is typically described by patients as an apoplectic event,
one that clearly stands out from other types of headaches
they may have previously experienced. Patients with
thunderclap headache often liken the sensation to an
explosion in their head or being struck in the head
Primary TCH is diagnosed when all other potential
underlying causes have been eliminated by diagnostic.
Secondary TCH have multiple causes (Table 1)
, and
Subarachnoid Hemorrhage is the most common cause.
It is important to recall that the headache, although
almost always present, is sometimes overshadowed by
other symptoms and this results in misdiagnosis. Prior
migraine, may lead to migraine as an incorrect diagnosis
and not working up patients because their headache has
responded to various analgesics, including triptans, is
another reason for misdiagnosis.
We performed a prospective cohort study of
consecutive patients with subarachnoid hemorrhage
secondary to rupture of an aneurysm who had received
EVT. The study was approved by the Hospital de
Clínicas Committee for Ethics in Human Research, and
all participants signed a voluntary informed-consent
form. The exclusion criteria were patients over 18 years
of age with the signs and symptoms of subarachnoid
hemorrhage secondary to rupture of an aneurysm who
had received EVT between June 1st, 2013, and June
1st 2014. The exclusion criteria were patients in coma,
confused or unable to complete the questionnaire
properly because of neurological disabilities, submitted
to neurosurgery, presence of non-saccular aneurysms
and loss of follow-up.
After embolization, these patients were interviewed
about a history of headache using a purpose-built
Table 1. Causes of Thunderclap Headache *
Most Common Causes of Thunderclap Headache
Reversible cerebral vasoconstriction syndrome
Subarachnoid hemorrhage
Less Common Causes of Thunderclap Headache
Cerebral infection
Cerebral venous sinus thrombosis
Cervical artery dissection
Complicated sinusitis
Hypertensive crisis
Intracerebral hemorrhage
Ischemic stroke
Spontaneous intracranial hypotension
Subdural hematoma
Uncommon Causes of Thunderclap Headache
Aqueductal stenosis
Brain tumor
Cardiac cephalgia
Giant cell arteritis
Pituitary apoplexy
Retroclival hematoma
Spontaneous spinal epidural hematoma
Third ventricle colloid cyst
*Although the exact incidence of each cause of thunderclap
headache is not well-dened, certain causes of thunderclap
headache are more common than others based upon how often
they present with thunderclap headache and the incidence of
the condition itself. For example, although pituitary apoplexy
might commonly present with thunderclap headache, as
pituitary apoplexy is an uncommon condition, it is an unlikely
cause of a patient’s thunderclap headache.
questionnaire by a neurologist. A questionnaire about the
presence of headache based on the ICHD (International
Classication of Headache Disorder) 3
in the 12 months prior to rupture was applied after EVT.
Depending on the characteristics of their headache at
the rst assessment, patients were classied as having
migraine with aura, migraine without aura or tension-type
The diagnosis of subarachnoid hemorrhage was
based on computed axial tomography (CAT), when this
failed to conrm the diagnosis, an analysis of cerebrospinal
uid following lumbar puncture was done to conrm the
hemorrhage. After the diagnosis, patients underwent
digital subtraction angiography (DSA) to conrm the
presence of and the site of the aneurysm, allowing the
EVT. Two experienced Interventional Neuroradiologists,
using remodeling technique, performed the coiling.
Patients were treated with Gugliemli Detachable Coils
(GDC, Stryker Neurovascular, Freemont, California, USA)
and Hyperform Occlusion Balloon System (Covidien,
Irvine, California, USA).
Thunderclap Headache In Ruptured Aneurysm
Esmanhotto BB, et al.
Headache Medicine, v.10, n.4, p.189-192, Out/Nov/Dez. 2019
Statistical Analysis
The non-parametric Mann-Whitney test was used
to correlate the aneurysm size with its localization. The
Fisher exact test was used to investigate the association
between qualitative variables, and the Jarque-Bera test
was used to test the variables for normality. P values of
less than 0.05 were considered signicant.
In total, we recruited 60 patients with RIA, 48 (80%)
were women and 12 men (20%), with a mean age of 49.5
± 12.9 years. Thirty-seven (61.7%) had a history of headache
in the 12 months prior to rupture of the aneurysm and
were distributed as follows: 16 (43.2%) with tension-type
headache; 11 (29.7%) with migraine without aura; nine (24.3%)
with migraine with aura; and one (2.7%) with non-specic
characteristics. (Table 2). From 60 cases, 31 (51.7%) had TCH
as clinical presentation of SAH. Arterial Hypertension and
tabagism were present in 18 (58%) patients and 10 (32%)
participants with TCH, respectively. In 23 (74%) participants
with TCH the aneurysm size were less than 10 mm, and in
8 (26%) were larger than 10 mm. The aneurysm size was
not statistically signicant in occurrence of TCH (p=0.08) In
48 patients (80%) the aneurysms were localized in anterior
circulation and 12 (20%) in posterior circulation, but no
difference in prevalence of TCH in this 2 subsets was shown.
(p=0.527)(Table 3).
Epidemiological studies in the Brazilian population
have shown the prevalence of migraine and tension-type
headache to be 15.2% and 13%, respectively
. In the
present study, the prevalence of both types of headache
in patients with an intracranial aneurysm was twice
as high: 33.4% for migraine (15% with aura and 18.4%
without aura) and 26.7% for tension-type headache.
Subarachnoid haemorrhage is the most common
cause of secondary TCH and should be the focus of
the initial assessment given the signicant associated
morbidity and mortality. Initial misdiagnosis and
subsequent rebleeding corresponds with a worsening
prognosis. Historically, the diagnosis of SAH was missed
on initial presentation in 11% to 25%25% of patients
presenting with TCH.
A study performed in 364 patients, with intracranial
aneurysms conrmed by angiography, evaluated
presence of warning signs (moderate or severe headache,
dizziness, nausea/vomiting, transitory sensitivity and/or
motor decit, loss of consciousness, visual or oculomotor
disturbances) preceding major hemorrhage.
Two specic groups are considered: 1) 78 patients
with SAH at admission (Group A). This group of
patients with referral and correct diagnosis at the
rst episode of non-catastrophic SAH is considered
a “recognized” minor leak; 2) 74 patients with SAH
and history of premonitory warning signs (Group B).
These patients had not identied minor leak and were
referred and diagnosed only at a second episode of
SAH. Headache described by the patients as sudden,
severe and unusual was the main symptom in Groups A
and B; in 82.5% of cases it was localized. Thunderclap
headache was an isolated symptom in 14.1 % of patients
in Group A and in 32.4% in Group B and in respectively
37.2% and 28.4% of cases it was associated with
nausea or vomiting.
The present study has shown the
prevalence of TCH was 51,7 %. And TCH associated with
nausea and vomiting was 75 %.
Table 2. Clinical characteristics of patients with primary headache and intracranial aneurysms before their rupture
Migraine with aura Migraine without aura TTH All types*
(n = 9) (n = 11) (n = 16) (n = 37)
Mean Age (years) 47 42,4 48,3 46,3
Thunderclap headache 6 (16,2%) 4 (10,8%) 10 (27%) 21 (56,8%)
Female 9 (24,3%) 8 (21,6%) 12 (32,4%) 30 (81%)
Male 0 3 (8,1%) 4 (10,9%) 7 (19%)
Arterial Hypertension 5 (13,5%) 5 (13,5%) 7 (19%) 18 (48,7%)
Smoker 5 (13,5%) 3 (8,1%) 4 (10,9%) 13 (35,1%)
Aneurysm size
<10 mm 5 (13,5%) 7 (19%) 14 (37,8%) 27 (73%)
10 - 24 mm 3 (8,1%) 1 (2,7%) 2 (5,4%) 8 (21,6%)
>24 mm 0 2 (5,4%) 0 2 (5,4%)
*Including nonspecic headache
Table 3. Presence of TCH according vascular territory
Aneurysm Localization
Anterior Circulation Posterior Circulation
n % n %
No 22 45,8% 7 58,3%
Yes 26 54,2% 5 41,7%
Total 48 100,0% 12 100,0%
p= 0,527
Thunderclap Headache In Ruptured Aneurysm
Esmanhotto BB, et al.
Headache Medicine, v.10, n.4, p.189-192, Out/Nov/Dez. 2019
In addition, a recent study identied the presence
of migraine as independent risk factor for rupture of an
intracranial aneurysm
The present study has limitations. Firstly, the patients
may have overlooked episodes of mild headache or
forgotten details of the pain in the 12 months prior to
treatment. Secondly, the number of participants was
In summary, we conclude that nearly half of
patients with ruptured intracranial aneurysms presented
thunderclap headache and there is no relation with size
aneurysm and vascular territory.
1. Suarez JI, Tarr RW, Selman WR. Cerebral aneurysms. N Engl
J Med 2006; 354: 387–96.
2. Wiebers DO, Whisnant JP, Forbes. Unruptured Intracranial
Aneurysms - Risk of Rupture and Risks of Surgical
Intervention. N Engl J Med 1998; 339: 1725–33.
3. Baron EP. Headache, Cerebral Aneurysms, and the Use of
Triptans and Ergot Derivatives. Headache 2015; 55: 739–47.
4. Headache Classication Committee of the International
Headache Society (IHS) The International Classication of
Headache Disorders, 3rd edition. (2018). Cephalalgia 2018;
38: 1–211.
5. Vlak MHM, Rinkel GJE, Greebe P, et al. Risk of rupture of an
intracranial aneurysm based on patient characteristics: A
case-control study. Stroke 2013; 44: 1256–1259.
6. Schwedt TJ. Thunderclap Headache. Headache 2015; 21:
7. Schwedt TJ, Matharu MS, Dodick DW. Thunderclap
headache. Lancet Neurol 2006; 5: 621–31.
8. Abraham MK, Chang W-TW. Subarachnoid Hemorrhage.
Emerg Med Clin N Am 2016; 34: 901–916.
9. Queiroz LP, Peres MFP, Piovesan EJ, et al. A nationwide
population-based study of migraine in Brazil. Cephalalgia
2009; 29: 642–649.
10. Queiroz LP, Peres MFP, Piovesan EJ, et al. A nationwide
population-based study of tension-type headache in Brazil.
Headache 2009; 49: 71–78.
11. Landtblom AM, Fridriksson S, Boivie J, et al. Sudden onset
headache: A prospective study of features, incidence and
causes. Cephalalgia 2002; 22: 354–60.
12. Linn FHH, Wijdicks EFM, Van Der Graaf Y, et al. Prospective
study of sentinel headache in aneurysmal subarachnoid
haemorrhage. Lancet 1994; 344: 590–593.
13. Bassi P, Bandera R, Loiero M, et al. Warning signs in
subarachnoid hemorrhage: a cooperative study. Acta
Neurol Scand 1991; 84: 277–281.