Lance (1976) described 21 cases of this type of headache, 16 in males and 5 in females. The headache took one of two forms: one in which pain typical of tension headache developed as sexual excitement increased, and another in which a severe, throbbing, “explosive” headache occurred at the time of orgasm and persisted for several minutes or hours (orgasmic headache). The latter headaches were of such abruptness and severity as to suggest a ruptured aneurysm but the neurologic examination was negative in every instance, as was arteriography in 7 patients who were subjected to this procedure. In 18 patients who were followed for a period of 2 to 7 years, no other neurologic symptoms developed. Characteristically, the headache occurred on several consecutive occasions and then disappeared. In cases of repeated coital headache, indomethacin has been effective. Of course, so-called orgasmic headache is not always benign; a hypertensive hemorrhage, rupture of an aneurysm or vascular malformation, carotid artery dissection, or myocardial infarction may occur during the exertion of sexual intercourse. While there is no authoritative direction, it is justified to perform a spinal tap if a sexual-related headache is the first occurrence of headache in a patient’s history.
This is a severe headache of very abrupt onset and numerous causes, most being less serious than the nature of the symptoms suggest. Of course, the headache of subarachnoid hemorrhage caused by rupture of a saccular (berry) aneurysm is among the most abrupt and dramatic of cranial pains (see Chap. 33). It was in relation to headaches of this nature that the term thunderclap was introduced by Day and Raskin. They attributed the symptoms to an unruptured cerebral aneurysm but the term is now used to denote headache of this description from various causes.
Patients have offered colorful descriptions, such as “being kicked in the back of the head.” Thunderclap headache, as pointed out by Dodick, has been a symptom of pituitary apoplexy, cerebral venous thrombosis, cervical arterial dissection, nonaneurysmal perimesencephalic hemorrhage, or hypertensive crisis (Table 9-4). To this list should be added diffuse idiopathic arterial spasm (Call-Fleming syndrome; see “Diffuse and Focal Cerebral Vasospasm” in Chap. 33) and cerebral vasospasm as the result of the administration of sympathomimetic or serotonergic drugs, including cocaine and the triptan group of medications for the treatment of migraine. The coital and exertional headaches described above may also be considered of this nature. Recurrent thunderclap pain may be particularly indicative of multifocal or diffuse vasospasm, as pointed out by Chen and colleagues, who found this vasculopathy in 39 percent of their patients with recurrent thunderclap pain.
Because the pain of thunderclap headache may be indistinguishable from that caused by subarachnoid hemorrhage, even to the extent of being accompanied by vomiting and acute hypertension, the diagnosis is clarified after lumbar puncture and cerebral imaging, and the pain resolves in hours or less. Most cases turn out to be idiopathic. Wijdicks and colleagues confirmed that thunderclap headache is usually a benign condition; among 71 patients followed for more than 3 years they found no serious cerebrovascular lesions. For this reason, these idiopathic thunderclap headaches have been presumed by some workers to be a form of migraine (“crash migraine”). This opinion is based in part on a history of preceding or of subsequent headaches and migrainous episodes in affected individuals; however, in our experience not all of such patients have had migraine in the past. There is a notable tendency for thunderclap headaches to recur as mentioned above.