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“TEMPO” IN THE DIFFERENTIAL DIAGNOSIS OF A THUNDER HEADACHE
O P Kapoor
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
All patients and doctors are afraid of a “thunder” headache. There are three serious (may be fatal) and vascular causes of such headaches which may be in fact sometime difficult to diagnose. For example-
1. Subarachnoid haemorrhage where rarely the MRI brain imaging may not help in the diagnosis.
2. Thrombosis of the small sagittal blood sinuses in the skull where MRI imaging may be reported as normal.
3. Dissection of carotid arteries where MRI imaging of brain will be normal.
But the help of CSF examination and Doppler studies of the neck can help.
The problem is that patients having common migraine headache sometimes insist that they have a “thunder” headache. Our Indian patients specially females can easily fool the family physicians with the associated “gestures” showing that the headache is so severe that they are going to die.
Under these circumstances an imaging of MRI may not solve the problem, but a good history taking can.
Yes, during the attack of migraine, the headache can become so severe that the patient and the doctors can label it as a thunder headache. On detailed questioning, it will be found that the patient of migraine had a slight headache when he got up in the morning. By noon it increased and by afternoon it was “thundering”!
A real thunder headache always has a “sudden” instantaneous onset when the patient was absolutely normal a few minutes earlier.
Of course a positive past history and a family history will give additional help in the diagnosis of migraine headache.
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