Neuroscience · Year 2 · from Neuroscience
Case 3: Thunderclap Headache - Subarachnoid Hemorrhage
Patient Presentation
Demographics: 48-year-old female
Chief Complaint: "Worst headache of my life" sudden onset 2 hours ago
History of Present Illness: The patient was exercising at the gym when she suddenly developed an extremely severe headache that reached maximum intensity within seconds. She describes it as "like being hit on the back of the head with a baseball bat." She immediately felt nauseated and vomited. The headache has persisted and remains severe. She has never had a headache like this before. She has mild neck stiffness. She has a history of hypertension and smokes half a pack of cigarettes daily.
Physical Examination:
- Vital signs: BP 178/102, HR 92, T 37.3C
- General: In obvious distress, prefers to lie still with eyes closed
- Neurological:
- Mental status: Alert, oriented, following commands
- Cranial nerves: Pupils equal and reactive; photophobic but eye movements intact
- Motor: 5/5 throughout
- Reflexes: 2+ symmetric
- Neck: Nuchal rigidity (stiff neck; resistance to passive flexion)
- Kernig and Brudzinski signs: Positive
Red Flag Assessment (SNOOP4):
- Sudden onset (thunderclap): YES - maximum severity within seconds
- Neurological signs: Meningismus present
- Older than usual migraine population: 48 years, no prior history
- Pattern change: First ever headache of this severity
Workup:
- CT head without contrast: Hyperdensity in the basal cisterns, Sylvian fissures bilaterally, and interhemispheric fissure consistent with subarachnoid hemorrhage
- CT angiography: 6 mm saccular aneurysm at the anterior communicating artery
Diagnosis: Aneurysmal subarachnoid hemorrhage
Treatment:
- ICU admission
- Blood pressure control (target SBP 120-140 to prevent rebleeding)
- Nimodipine 60 mg every 4 hours for vasospasm prevention
- Pain management
- Neurosurgical/neurointerventional consultation
- Endovascular coiling of aneurysm performed within 24 hours
Clinical Course: Aneurysm was successfully coiled. The patient developed mild vasospasm on day 7 detected by transcranial Doppler, managed with hemodynamic augmentation. She was discharged on day 14 with minimal residual headache. At 3-month follow-up, she had returned to work with no significant deficits.
Clinical Pearl: Thunderclap headache (maximum intensity within seconds to one minute) is a neurological emergency requiring immediate evaluation for subarachnoid hemorrhage. CT is highly sensitive (>95%) within 6 hours but sensitivity decreases over time. If CT is negative but clinical suspicion remains high, lumbar puncture is mandatory to look for xanthochromia and RBCs. Approximately 12% of patients presenting with thunderclap headache have SAH. The key teaching point: a sudden, severe, "worst ever" headache demands evaluation regardless of how well the patient looks.
Clinical Image
Image Description: Illustration depicting the characteristic visual aura of migraine - a scintillating scotoma appearing as zigzag or fortification spectra lines (resembling castle battlements) that begin near central vision and gradually expand peripherally over 20-30 minutes. This cortical spreading depression moves across the visual cortex at approximately 3 mm per minute.
Attribution: Image from Wikipedia (https://en.wikipedia.org/wiki/Scintillating_scotoma), Creative Commons license.