Article Text

Download PDFPDF
Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study
  1. Tom Roberts1,2,
  2. Daniel E Horner3,4,
  3. Kevin Chu5,6,
  4. Martin Than7,
  5. Anne-Maree Kelly8,9,
  6. Sharon Klim9,10,
  7. Frances Kinnear11,12,
  8. Gerben Keijzers13,14,
  9. Mehmet Akif Karamercan15,
  10. Tissa Wijeratne16,
  11. Sinan Kamona17,18,
  12. Win Sen Kuan19,20,
  13. Colin A Graham21,
  14. Richard Body22,23,
  15. Said Laribi24,25
  16. on behalf of the HEAD study investigators
  1. 1 Trainee Emergency Research Network (TERN), The Royal College of Emergency Medicine, London, UK
  2. 2 Emergency Department, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
  3. 3 Emergency/Critical Care Department, Salford Royal NHS Foundation Trust, Salford, UK
  4. 4 Division of Infection Immunity and Respiratory Medicine, The University of Manchester, Manchester, England, UK
  5. 5 Department of Emergency, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
  6. 6 Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, Queensland, Australia
  7. 7 Emergency Department, Christchurch Hospital, Christchurch, Canterbury, New Zealand
  8. 8 JECEMR, Western Health, St Albans, Victoria, Australia
  9. 9 Department of Emergency Medicine, The University of Melbourne, Melbourne, Victoria, Australia
  10. 10 Joseph Epstein Centre for Emergency Medicine Research at Western Health, St Albans, Victoria, Australia
  11. 11 Emergency, Prince Charles Hospital, Chermside, Queensland, Australia
  12. 12 Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
  13. 13 Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
  14. 14 Department of Emergency Medicine, Bond University, Gold Coast, Queensland, Australia
  15. 15 Department of Emergency Medicine, Gazi University, Faculty of Medicine, Ankara, Turkey
  16. 16 Department of Neurology, La Trobe University, Melbourne, Victoria, Australia
  17. 17 School of Medicine, University of Auckland, Auckland, New Zealand
  18. 18 Auckland District Health Board, Auckland, New Zealand
  19. 19 Emergency Medicine, National University Health System, Singapore
  20. 20 Department of Surgery, National University Singapore Yong Loo Lin School of Medicine, Singapore
  21. 21 Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
  22. 22 Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
  23. 23 Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
  24. 24 Emergency Medicine, University Hospital of Tours, Tours, France
  25. 25 EUSEM Research Network, Aarselaar, Belgium
  1. Correspondence to Dr Tom Roberts, Trainee Emergency Research Network (TERN), The Royal College of Emergency Medicine, London, UK; tomkieranroberts{at}


Background Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as ‘thunderclap’ undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation.

Methods This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test.

Results 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases—significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache.

Conclusions Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.

  • headache
  • imaging

Data availability statement

No data are available. N/A.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

No data are available. N/A.

View Full Text


  • Handling editor Jason E Smith

  • Twitter @ternfellow, @kellyam_jec, @combatstrokeSL, @richardbody

  • Collaborators HEAD study group: Catherine Lunter (Coffs Harbour Hospital, New South Wales, Australia), Rochelle Facer (Concord Repatriation Hospital, New South Wales, Australia), David Thomson (Port Macquarie Base and Kempsey District Hospitals, New South Wales, Australia), Robert Day (Royal North Shore Hospital, New South Wales, Australia), Greg McDonald (Sydney Adventist Hospital, New South Wales, Australia), Sarah Jones (Tamworth Regional Hospital, New South Wales, Australia), Julian Cochrane (Orange Base Hospital, New South Wales, Australia), Stephen Gourley (Alice Springs Hospital, Northern Territory, Australia), Mark Ross & Vinay Gangathimmaiah (Royal Darwin Hospital, Northern Territory, Australia), Kim Hansen (St Andrew’s War Memorial Hospital, Queensland, Australia), Frances B Kinnear (The Prince Charles Hospital, Queensland, Australia), Gerben Keijzers (Gold Coast University Hospital, Queensland, Australia), Kevin Chu (Royal Brisbane and Women’s Hospital, Queensland, Australia), Paul Bowe (Robina Hospital, Queensland, Australia), Raymund de la Cruz (Lyell McEwin and Modbury Hospitals, South Australia, Australia), Daniel Haustead (The Queen Elizabeth and Royal Adelaide Hospitals, South Australia, Australia), Jean Moller (University Hospital Geelong, Victoria, Australia), Katie Walker (Cabrini Malvern, Victoria, Australia), Richard D Smith (Bendigo Health, Victoria, Australia), Ron Sultana (Epworth Healthcare, Victoria, Australia), John Pasco (Werribee Mercy Hospital, Victoria, Australia), Neil Goldie and Andis Graudins (Monash Health, Victoria, Australia), Rosamond Dwyer (Peninsula Health, Victoria, Australia), George Plunkett (Melbourne Health, Victoria, Australia), Anne-Maree Kelly (Western Health, Victoria, Australia), Hugh Mitenko (WA Country Health Service, Western Australia), Michael Lovegrove (Joondalup Health Campus, Western Australia), Ben Smedley (Rockingham General Hospital, Western Australia), Colin A Graham and Ling Yan Leung (Prince of Wales Hospital, Hong Kong SAR), Win Sen Kuan and Ying Wei Yau (National University Hospital, Singapore), Wei Ming Ng (Ng Teng Fong General Hospital, Singapore), Ranjeev Kumar (Khoo Teck Puat Hospital, Singapore), Dennis Wen Jie Chia (Sengkang General Hospital, Singapore), Said Laribi (CHU Tours, Tours, France), Mounir Hilal and Rarthtana Mil (CH Vendôme, France), Audrey Gerineau (CHR Orléans, France), Matthew J Reed (Emergency Medicine Research Group Edinburgh [(EMERGE]), Royal Infirmary of Edinburgh, UK), Daniel Horner (Salford Royal NHS Foundation Trust, Salford, UK), Edward Carlton and Tom Roberts (North Bristol NHS Trust, UK), Girish Boggaram and Jayne Foot (Musgrove Park Hospital, Taunton, UK), Andy Appleboam, Rachel Goss and Hamza Malik (Royal Devon and Exeter NHS Foundation, UK), Richard Body (Manchester Royal Infirmary, Manchester, UK), John-Paul Williamson (Royal Oldham Hospital, Oldham, UK), Adela Golea and Sonia Luka (University County Hospital Cluj-Napoca, Romania), Huseyin Avni Demir (University of Health Sciences Mehmet Akif Inan Training and Research Hospital, Department of Emergency Medicine, Şanlıurfa Turkey), Şafak Öner Gülpinar (Tokat Erbaa Government Hospital, Tokat, Turkey), Lale Tolu (Bursa Çekirge Government Hospital of Emergency Service, Bursa, Turkey), Muhammet Hacimustafaoğlu (Hakkari Yuksekova Government Hospital, Hakkari, Turkey), Mehmet A Karamercan (Gazi University Faculty of Medicine Department of Emergency Medicine, Ankara, Turkey), Elif Çelikel (Numune Research and Training Hospital, Department of Emergency Medicine, Ankara, Turkey), Çilem Çaltili (Unıversıty Of Health Sciences Bağcılar Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey), Selahattin Gürü (Yıldırım Beyazıt University Faculty of Medicine Department of Emergency Medicine, Ankara, Turkey), Gülşah Yavuz (Antalya Ataturk Government Hospital of Medicine, Department of Emergency Medicine, Antalya, Turkey), Franck Verschuren (Institute of Experimental and Clinical Research, Emergency Department, Saint-Luc University Hospital, Brussels, Belgium), Christopher Ramos (Emergency Department, Saint-Luc University Hospital, Brussels, Belgium), Paule Denoel and Nicolas Wilmet (Saint Michel, Clinique de l'Europe, Etterbeek, Brussels), Michael Vandoorslaert and Alessandro Manara (Saint Elisabeth, Clinique de l'Europe, Uccle, Brussels), Adeline Higuet (CHR Hal, Belgium), Amichai Sheffy (Tel-Aviv Sourasky Medical Center, Israel), Sinan Kamona and Peter Jones (University of Auckland, School of Medicine, Auckland, New Zealand), Mai Nguyen (Wellington Hospital, Wellington, New Zealand), Anne Clarke (Hutt Valley Hospital, Lower Hutt, New Zealand), Sierra Beck (Dunedin Hospital, Dunedin, New Zealand), Andrew Munro (Nelson Hospital, Nelson, New Zealand), Kim M Yates (North Shore and Waitakere Hospitals, Waitematā District Health Board, New Zealand), James Weaver (Christchurch Hospital, Christchurch, New Zealand), Deborah Moore and Stuart Innes (Tauranga Hospital, Tauranga, New Zealand), Karina Walters (Taranaki District Health Board, New Zealand), Koen Simons (Statistician, Office for Research, Western Health and University of Melbourne, Victoria, Australia). Steering Committee: Anne-Maree Kelly, Kevin Chu, Tissa Wijeratne, Frances B Kinnear, Gerben Keijzers, Sinan Kamona, Win Sen Kuan, Colin Graham, Richard Body, Said Laribi, Sharon Klim, Koen Simons, Mehmet Karamercan, Tom Roberts. Co-ordinating Centre, Western Health, Victoria, Australia: Anne-Maree Kelly, Sharon Klim and Kerrie Russell.

  • Contributors A-MK conceived the idea for the study. A-MK was responsible for the initial study design, which was refined with the help of the steering committee. KC provided the statistical plan. TR led the dissemination of the study in UK. KC provided the statistics. TR, DEH, A-MK and KC critically revised successive drafts of the manuscript and approved the final version. The study management group is responsible for the conduct of the study. TR is responsible for the content this manuscript.

  • Funding Royal College of Emergency Medicine provided part funding.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the employers.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.