Headache (Thunderclap)
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with acute severe (‘thunderclap’) headache.
Date reviewed: June 2014
Date of next review: May 2023
Published: October 2014
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page |
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| 1a |  |
Subarachoid Haemorrhage Image 1a and 1b (Computed Tomography): Pre and post-contrast images of a large left sided subarachnoid haemorrhage with blood surrounding the Circle of Willis (Image 1a arrow) and extending into the ventricles (Image 1b arrow). |
| 1b |  |
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| 1c |  |
Left Posterior Communicating Cerebral Artery Aneurysm
Image 1c (CT Angiography): Image from the same patient demonstrating a left sided posterior communicating cerebral artery aneurysm (arrow). |
| 2 |  |
Ruptured Berry Aneurysm Image 2 : Post-mortem specimen showing a ruptured berry aneurysm arising from the left middle cerebral artery (arrow) with extensive haemorrhage within the subarachnoid space. |
| 3 |  |
Subarachnoid Haemorrhage Image 3 : Post-mortem specimen showing haemorrhage into the subarachnoid space overlying the frontal and temporal lobes bilaterally. |
Teaching Points
Teaching Points
- CT is the initial investigation of choice in the assessment of thunderclap headache
- CT has a sensitivity of 90% for the detection of subarachnoid haemorrhage (SAH)
- A normal CT does NOT exclude SAH
- Lumbar puncture is required after a negative CT
- CT angiography and digital subtraction angiography may be used in the investigation of cerebral aneurysms
- Treatment of aneurysms may be by interventional radiology (coiling) or neurosurgery (clips)
- CT may reveal an alternative cause of thunderclap headache (such as cerebral venous thrombosis)
References
References
Date of literature search: June 2014
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407-36. (Review article)
- Field AG, Wang E. Evaluation of the nontraumatic headache: an evidence based approach. Emerg Med Clin North Am. 1999;17(1):127-52. (Review article)
- Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid haemorrhage: a statement for healthcare professionals from a special writing group of the stroke council, American Heart Association. Stroke. 1994;25(11):2315-28. (Review article)
- Kassell NF, Torner JC, Haley EC Jr, et al. The international cooperative study on the timing of aneurysm surgery, part 1: overall management results. J Neurosurg. 1990;73:18-36. (Level II evidence). View the reference
- Van der Wee N, Rinkel GJ, Hasan D, et al. Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan? J Neurol Neurosurg Psychiatry. 1995;58:357-9. (Level II evidence). View the reference
- Morgenstern LB, Luna-Gonzales H, Huber JC Jr, et al. Worst headache and subarachnoid hemorrhage: Prospective, Modern computed tomography and spinal fluid analysis. Ann Emerg Med. 1998;32:297-304. (Level II evidence). View the reference
- Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Emond M, Symington C, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343:d4277. (Level I evidence)
- Lee SK, terBrugge KG. Cerebral venous thrombosis in adults: the role of imaging evaluation and management. Neuroimaging Clin N Am. 2003;13(1):139-52. (Review article)
- Sahin N, Solak A, Genc B, Bilgic N. Cerebral venous thrombosis as a rare cause of subarachnoid hemorrhage: case report and literature review. Clin Imaging. 2014;38(4):373-9. (Review article)
- Anderson GB, Steinke DE, Petruk KC, Ashforth R, Findlay JM. Computed tomographic angiography versus digital subtraction angiography for the diagnosis and early treatment of ruptured intracranial aneurysms. Neurosurgery. 1999;45(6):1315-20; discussion 20-2. (Level II evidence)
- Kathuria S, Deveikis JP, Westesson PL, Gandhi D. Improved diagnosis of actively bleeding aneurysm on CT angiography using delayed CT images. Eur J Radiol. 2011;79(2):328-31. (Review article)
- Desai S, Friedman JA, Hlavin J, Kash F. Actively bleeding intracranial aneurysm demonstrated by CT angiography. Clin Neurol Neurosurg. 2009;111(1):94-6. (Review article)
- Hashimoto H, Iida J, Hironaka Y, Okada M, Sakaki T. Use of spiral computerized tomography angiography in patients with subarachnoid hemorrhage in whom subtraction angiography did not reveal cerebral aneurysms. J Neurosurg. 2000;92(2):278-83. (Level II evidence)
- Matsumoto M, Sato M, Nakano M, Endo Y, Watanabe Y, Sasaki T, et al. Three-dimensional computerized tomography angiography-guided surgery of acutely ruptured cerebral aneurysms. J Neurosurg. 2001;94(5):718-27. (Level II evidence)
- Velthuis BK, van Leeuwen MS, Witkamp TD, Ramos LM, Berkelbach van der Sprenkel JW, Rinkel GJ. Surgical anatomy of the cerebral arteries in patients with subarachnoid hemorrhage: comparison of computerized tomography angiography and digital subtraction angiography. J Neurosurg. 2001;95(2):206-12. (Level II evidence)
- Lu L, Zhang LJ, Poon CS, Wu SY, Zhou CS, Luo S, et al. Digital subtraction CT angiography for detection of intracranial aneurysms: comparison with three-dimensional digital subtraction angiography. Radiology. 2012;262(2):605-12. (Level II evidence)
- Donmez H, Serifov E, Kahriman G, Mavili E, Durak AC, Menku A. Comparison of 16-row multislice CT angiography with conventional angiography for detection and evaluation of intracranial aneurysms. Eur J Radiol. 2011;80(2):455-61. (Level II evidence)
- He W, Hauptman J, Pasupuleti L, Setton A, Farrow MG, Kasper L, et al. True posterior communicating artery aneurysms: are they more prone to rupture? A biomorphometric analysis. J Neurosurg. 2010;112(3):611-5. (Level II evidence)
- Struffert T, Doelken M, Adamek E, Schwarz M, Engelhorn T, Kloska S, et al. Flat-detector computed tomography with intravenous contrast material application in experimental aneurysms: comparison with multislice CT and conventional angiography. Acta Radiol. 2010;51(4):431-7.(Level II evidence)
- Tipper G, JM UK-I, Price SJ, Trivedi RA, Cross JJ, Higgins NJ, et al. Detection and evaluation of intracranial aneurysms with 16-row multislice CT angiography. Clin Radiol. 2005;60(5):565-72. (Level II evidence)
- Yoon DY, Lim KJ, Choi CS, Cho BM, Oh SM, Chang SK. Detection and characterization of intracranial aneurysms with 16-channel multidetector row CT angiography: a prospective comparison of volume-rendered images and digital subtraction angiography. AJNR Am J Neuroradiol. 2007;28(1):60-7. (Level II evidence). View the reference
- Westerlaan HE, van Dijk JM, Jansen-van der Weide MC, de Groot JC, Groen RJ, Mooij JJ, et al. Intracranial aneurysms in patients with subarachnoid hemorrhage: CT angiography as a primary examination tool for diagnosis - systematic review and meta-analysis. Radiology. 2011;258(1):134-45.(Level I evidence). View the reference
- White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology. 2000;217(2):361-70. (Level II evidence). View the reference
- Rinkel GJ, Wijdicks EF, Hasan D et al. Outcome in patients with subarachnoid hemorrhage and negative angiography according to pattern of haemorrhage on computed tomography. Lancet. 1991;338:964-8. (Level II evidence). View the reference
- Rinkel GJ, Wijdicks EF, Vermeulen M et al. The clinical course of perimesencephalic subarachnoid haemorrhage. Ann Neurol. 1991;29:463-8. (Level II evidence). View the reference
- Ringelstein A, Mueller O, Goericke SL, Moenninghoff C, Sure U, Wanke I, et al. Benefit of Second Catheter Angiography in Patients with Nontraumatic Subarachnoidal Hemorrhage. Clin Neuroradiol. 2013:(Ahead of print - Level III evidence)
- Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267-74. (Level I evidence)
- Edlow JA, Wyer PC. Evidence-based emergency medicine/clinical question. How good is a negative cranial computed tomographic scan result in excluding subarachnoid hemorrhage? Ann Emerg Med. 2000;36(5):507-16. (Review article)
- Vermeulen M, van Gijn J. The diagnosis of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1990;53:365-72. (Review article)
- Wijdicks EFM, Kerkhoff H, van Gijn J. Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid haemorrhage. Lancet. 1988;2:68-70. (Level III evidence)
- Harling DW, Peatfield RC, Van Hille PT, Abbott RJ. Thunderclap headache: is it migraine? Cephalagia. 1989;9:87-90. (Level III evidence)
- Tsai FY, Wang AM, Matovich VB, et al. MR staging of acute dural sinus thrombosis: correlation with venous pressure measurements and implications for treatment and prognosis. AJNR Am J Neuroradiol. 1995;16:1021-9. (Level III evidence)
- Lee SK, terBrugge KG. Cerebral venous thrombosis in adults: the role of imaging evaluation and management. Neuroimaging Clin N Am. 2003;13:139-52. (Review article)
- Forbes KP, Pipe JG, Heiserman JE. Evidence for cytotoxic edema in the pathogenesis of cerebral venous infarction. AJNR Am J Neuroradiol. 2001;22:450-5. (Level III evidence)
- van Gijn J, van Dongen KJ, Vermeulen M, Hijdra A. Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology. 1985;35(4):493-7. (Level III evidence)
- Marder CP, Narla V, Fink JR, Tozer Fink KR. Subarachnoid hemorrhage: beyond aneurysms. AJR Am J Roentgenol. 2014;202(1):25-37. (Review article). View the reference
- Velthuis BK, Rinkel GJ, Ramos LM, Witkamp TD, van Leeuwen MS. Perimesencephalic hemorrhage. Exclusion of vertebrobasilar aneurysms with CT angiography. Stroke. 1999;30(5):1103-9. (Level II evidence). View the reference
- van der Schaaf IC, Velthuis BK, Gouw A, Rinkel GJ. Venous drainage in perimesencephalic hemorrhage. Stroke. 2004;35(7):1614-8. (Level III evidence). View the reference
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Consent to Procedure or Treatment Radiation Risks of X-rays and Scans Computed Tomography (CT) Angiography Magnetic Resonance Angiography (MRA) |
Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children Interventional Radiological Treatment of Intracranial Aneurysms |
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