Managing Patients With Nontraumatic, Severe, Rapid-Onset Headache

Severe rapid-onset headache, sometimes called thunderclap headache, is a relatively common emergency department (ED) chief complaint. Although these headaches have been defined as "peaking within one minute,"1,2 some have questioned this rigid time criterion.3 In one study of subarachnoid hemorrhage diagnosis, the interobserver agreement in the ED for "thunderclap" onset was only moderate (κ=0.49), and 6 (of 132) subarachnoid hemorrhage patients reported time to peak intensity of 1 hour.4 For these reasons, I do not strictly use "sudden onset" in practice, but these patients generally recall exactly what they were doing at headache onset.

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