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Richard C. Senelick, M.D. Headshot

Would You Recognize a 'Headache That Kills'?

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Jake, an experienced weightlifter with years of experience and training, slowly pushed a heavy weight bar over his head. Just as it passed his forehead, a mind-numbing explosion of pain in his head brought him to his knees. Carmen slowly sank down into her hot bath to enjoy her favorite part of the day, a quiet soak in the tub. As she leaned back to breathe in the steam, her head erupted with the harshest pain she had ever felt. Blake and Julia's kids had finally fallen asleep, leaving the couple to enjoy a romantic evening. But just as Blake was about to reach his orgasm, his head burst into blazing pain.

All three experienced the worst headache of their lives. But who needs to worry if they just had a deadly headache?

It may sound melodramatic, but a new study, "Headaches that Kill: A retrospective study of incidence, etiology and clinical features in cases of sudden death" looks at the characteristics of people who die shortly after complaining of the sudden onset of a severe headache. Recognizing a severe headache as a deadly headache is difficult. Headaches are so common that a Google search yields over 63 million results. There are sinus headaches, tension headaches, migraines and stress headaches -- but what makes a deadly headache different? If the vast majority of people will experience a headache during their lives, how do you know if one particular headache is the one headache that requires a trip to the emergency room?

The Thunderclap

All three of these people had that explosive and unexpected headache known as a "thunderclap headache." Imagine that you are sitting quietly in your favorite chair when an unexpected lightning flash and thunderclap startle you. Now imagine that this takes place inside your head. Headaches are common, so do you go to the emergency room, call your doctor the next morning, or just wait to see if it ever occurs again? The right decision might save your life.

Doctors worry that blood leaking from a brain aneurysm cases these thunderclap headaches. These blood vessels have weak spots that gradually increase in size until they rupture, severe brain damage or even death. The warning headache has been called a "sentinel" headache, but only occurs in 10-43 percent of people with an aneurysmal rupture. These small leaks that lead to the thunderclap headache can occur days to weeks before a massive rupture.

The problem lies in misdiagnosis. These headaches are often ignored, or blamed on other, harmless situations that can also cause explosive headaches. The study considered "blue flags," which do not signal anything urgent, and "red flags," which alert the patient and doctor that immediate action is needed. At the bottom line, there are three important red flags associated with death:

  • Being over 50 years of age
  • Loss of consciousness or collapse
  • Feeling that it's the worst headache of one's life

Their recommendation, even though the sudden onset of headache is common and most situations are benign: Go to the emergency room and insist on a CT scan of your brain.

What Else Could It Be?

Misdiagnoses aside, how does Jake know that his thunderclap headache isn't a result of the number of other conditions that cause such sudden, painful headaches? There are several other situations that may cause a non-lethal thunderclap headache.

  • Exertional Headaches: Like our weightlifter, people can develop a severe headache during or after physical exercise. Exertional headaches occur with physical exercise and usually resolve in a short period of time.
  • Sexual or Coital Headaches: Some individuals experience a sudden explosive headache just prior to or at the moment of orgasm. The headache usually lasts 30 minutes to a few hours and can create a great deal of anxiety about the next sexual encounter, but are not deadly.
  • Primary Cough Headache: These unusual headaches tend to occur in older people and don't last as long as the other headaches. Exertion and coughing force a Valsalva maneuver , which is similar to what you experience in your throat when you bear down to have a bowel movement or lift a heavy weight.

Another group of people have thunderclap headaches for no reason at all. They occur "out of the blue" and usually do not recur for long periods of time. All of the medical studies are normal and no one knows why they occur.

What Should You Do?

It certainly seems confusing. The sudden onset of an explosive headache may be the only warning of a deadly condition. On the other hand, the vast majority of the time these headaches are benign and not a cause for alarm. I would argue that the risk of doing nothing is too high. We educate people to call 911 and go to the emergency room if they think they are having a stroke, or to race to the emergency room if they think they are having a heart attack. Most of us understand that that sense of urgency.

In the same vein, if you experience the new onset of an explosive "thunderclap" headache that you consider the worst headache of your life, go to the emergency room. Insist that they perform a CT scan of your brain. The latest generation of scanners is nearly 100 percent accurate in detecting blood in the brain. That accuracy declines rapidly over time, so don't object if the doctor also wants to do a spinal tap. It just may save your life.

You wouldn't ignore crushing chest pain, so don't ignore a raging thunderstorm in your head.

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