a case of a thunderclap headache andy jagoda, md, facep

A Case of a A Case of a Thunderclap HeadacheThunderclap Headache

Andy Jagoda, MD, FACEP


Andy S. Jagoda, MD, FACEPAndy S. Jagoda, MD, FACEP

Professor and Vice ChairProfessor and Vice ChairResidency Program DirectorResidency Program Director

Department of Emergency MedicineDepartment of Emergency MedicineMount Sinai School of MedicineMount Sinai School of Medicine

New York, NYNew York, NY


ObjectivesObjectives

• Review the focused neurologic exam in a patient with a sudden onset severe headache

• Review the differential diagnosis of sudden onset, severe headache

• Review the diagnostic approach to a patient with a sudden onset, severe headache


Case of Sudden Onset Severe HeadacheCase of Sudden Onset Severe Headache

• 32 year old female complained of a sudden,

acute onset vertex headache radiating into

her neck for 3 hours associated with nausea

and lightheadedness.

• No PMH: No past history of headache

• Medications: None

• Family history: Not significant


Case ContinuedCase ContinuedAppearance: 32 year old female, alert,

cooperative but appeared uncomfortable, holding the top of her head

VSS: 118/76, 72, 16, 98.6 Head: AtraumaticNeck: Nontender, suppleHeart: Regular, no murmurs, no clicks Lungs: ClearAbd: Soft, nontender


Key Components of the Key Components of the Physical ExamPhysical Exam

• Mental status• Cranial nerve II– Fundoscopic exam looking for papilledema– Swinging flashlight test for afferent nerve defect

• Cranial nerve III– Pupil size looking for evidence of extrinsic

compression of the parasympathetic fibers

• Cranial IV and VI– The two longest intracranial cranial nerves


Differential Diagnosis of Severe Differential Diagnosis of Severe Sudden Onset HeadacheSudden Onset Headache

• Subarachnoid hemorrhage

• Venous sinus thrombosis

• Idiopathic intracranial hypertension

• Carotid or vertebral artery dissection


Does response to therapy predict the etiology Does response to therapy predict the etiology of an acute severe headache?of an acute severe headache?

• All HA pain is mediated by serotonin receptors• Case series / case reports (Class III evidence)– Seymour. Am J Emerg Med 1995. 3 patients treated

with ketorolac or prochlorperazine with resolution of headache / Discharged / All with catastrophic outcomes

– Gross. Headache 1995. 3 cases of meningitis with resolution of pain with DHE and metoclopramide

• Pain response can not be used as an indicator or the underlying etiology of an acute headache.

ACEP Clin Pol. Ann Emerg Med 2002;108ACEP Clin Pol. Ann Emerg Med 2002;108


Which patients with acute headache require Which patients with acute headache require neuroimaging in the ED?neuroimaging in the ED?

• Neuroimaging is obtained to assess for treatable lesions: SAH, CVT, tumors, hydrocephalus– (Less tangible: Patient reassurance)

• Abnormal neuro exam increases the likelihood of a positive CT 3 times (95% CI 2.3-4)

• Normal neuro exam is not predictive• Location, vomiting, headache waking patient

up, worsening with valsalva are not predictive

ACEP Clin Pol. Ann Emerg Med 2002;108ACEP Clin Pol. Ann Emerg Med 2002;108



• Severe sudden onset headache: – Lledo Headache 1994, prospective study: 9 of 27

had SAH (only 4 had a positive CT)–Mills Ann Emerg Med 1986, prospective study 42

patients: 29% with worst headache had a positive CT

• Headache in the HIV patient:– Lipton Headache 1991, prospective 49 patients:

35% had mass lesion–Rothman Acad Emerg Med 1999, prospective 110

pts: 24% had a focal lesion



• Patients presenting with an acute HA and an abnormal neurologic exam should have an emergent head CT

• Patients presenting with a sudden severe HA should have an emergent head CT

• HIV patients with a new type of headache should have an urgent head CT

• Patients over the age of 50 with a new type of headache should have an urgent neuroimaging study


What are the indications for LP in acute HA?What are the indications for LP in acute HA?

• Suspected SAH in a patient with a normal head CT–CT is 90 – 98% sensitive for acute SAH–Sensitivity decreases over time

• Suspected meningitis– LP without CT in patients with normal neuro exam

including normal mental status and normal fundoscopic exam

• Suspected idiopathic intracranial hypertension–Headache with papilledema–Normal CT


Is there a need for an emergent angiography in the Is there a need for an emergent angiography in the patient with a sudden onset, severe headache who has patient with a sudden onset, severe headache who has

a negative CT / LP?a negative CT / LP?

• Level C recommendation: Patients with a sudden onset, severe HA who have negative findings in a head CT scan, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up arranged with their primary care provider or neurologist.


ConclusionsConclusions• HA evaluation requires a careful neurologic exam

that focuses on the mental status, and CN II, III, IV, VI• Tx response does not predict the underlying etiology• Patients with sudden severe HA require a CT; if

negative a LP– If the LP is negative, consider observing and repeating

if the onset of headache was less than 12 hours from the test

• If CT and LP are negative, consider unruptured aneurysmal disease and discuss need for cerebral angiography / MRA– Test can be done as an outpatient


Questions??Questions??

[email protected]@ferne.org

Andy Jagoda, MDAndy Jagoda, [email protected]

jagoda_ha_bic_symp_sea_0805.ppt 8/3/2005 5:02 PM Andy Jagoda, MD, FACEP

a case of a thunderclap headache andy jagoda, md, facep

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