When the headache feels like a lightning strike

Every one of us has faced the fear that our headache symptoms might just be a sign of something far worse. We worry about cancer, stroke, anyeurism, and the ethereal unknown. On one hand, finding such a problem would explain our misery and hopefully have a solution. For example, several years ago a family member contacted me in desperation. She was having horrible headaches that did not respond to any kind of pain medicine, even powerful narcotics administered in the ER.  Further investigation by her doctor revealed a benign tumor that was putting pressure on her cranial nerves. After surgery and an extended recovery, she was once again, headache-free.

If only…right?

Well, sometimes terrible headaches do have a defined cause. Any time we experience a sudden, severe headache pain, it should be checked out. In the absence of a defined cause, these symptoms can mean the presence of Thunderclap Headache.

On occasion, these symptoms can also be triggered by exercise, coughing, or sexual activity. In these cases, the diagnosis would be a specific headache disorder (Primary Cough Headache, Primary Exercise Headache, or Primary Headache associated with sexual activity).

However, these same symptoms can be caused by other serious problems

  • Subarachnoid haemorrhage
  • Cerebral venous thrombosis
  • Aneurysm
  • Arterial dissection
  • Reversible vasoconstriction syndrome
  • Pituitary apoplexy
  • Meningitis
  • Colloid cyst of the third ventricle
  • CSF hypotension
  • Acute sinusitis

Thunderclap headache is only diagnosed when a thorough examination eliminates all possible causes. Brain imaging, vascular imaging, and CSF pressure through lumbar puncture may be required. The presence of primary thunderclap headache is actually quite rare. It is more likely to be a symptom of a more serious problem

So…if you ever experience sudden and severe headache pain that ramps up to maximum in less than a minute and doesn’t resolve within 5 minutes or less, please get it checked out.


The official diagnostic criteria from the International Classification of Headache Disorders:

4.4 Primary thunderclap headache

Previously used term: Benign thunderclap headache.

Coded elsewhere: 4.1 Primary cough headache, 4.2 Primary exercise headache and 4.3 Primary headache associated with sexual activity can all present as thunderclap headache. When such headache is attributed uniquely to one of these triggers, it should be coded accordingly as one of these headache types.

Description: High-intensity headache of abrupt onset, mimicking that of ruptured cerebral aneurysm, in the absence of any intracranial pathology.

Diagnostic criteria:

  1. Severe head pain fulfilling criteria B and C
  2. Abrupt onset, reaching maximum intensity in <1 minute
  3. Lasting for ≥5 minutes
  4. Not better accounted for by another ICHD-3 diagnosis.

Comment: Evidence that thunderclap headache exists as a primary disorder is poor: the search for an underlying cause should be expedited and exhaustive. Thunderclap headache is frequently associated with serious vascular intracranial disorders, particularly subarachnoid haemorrhage: it is mandatory to exclude this and a range of other such conditions including intracerebral haemorrhage, cerebral venous thrombosis, unruptured vascular malformation (mostly aneurysm), arterial dissection (intra- and extracranial), reversible cerebral vasoconstriction syndrome (RCVS) and pituitary apoplexy. Other organic causes of thunderclap headache are meningitis, colloid cyst of the third ventricle, CSF hypotension and acute sinusitis (particularly with barotrauma). 4.4 Primary thunderclap headache should be a diagnosis of last resort, reached only when all organic causes have been demonstrably excluded. This implies normal brain imaging, including the brain vessels, and/or normal CSF. Of note, vasoconstrictions may not be observed in the early stage of RCVS. For this reason, probable primary thunderclap headache is not a diagnosis that should be made, even temporarily.

NOTE: Corrections made on 8/10/2016 to reflect the accurate duration of Thunderclap Headache.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.
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