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a From the University Department of Neurology, b Julius Center for Patient Oriented Research, Utrecht, The Netherlands
Correspondence to: Dr F H H Linn, University Department of Neurology, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands. Telephone 0031 30 2507975; fax 0031 30 2542100; email G.J.E.Rinkel{at}neuro.azu.nl
Received 16 January 1998 and in revised form 19 May 1998;
Accepted 15 June 1998
One third of patients with aneurysmal subarachnoid haemorrhage
(ASAH) present with headache only. A prompt diagnosis is crucial, but
these patients must be distinguished from patients with
non-haemorrhagic benign thunderclap headache (BTH). The headache
characteristics and associated features at onset in subarachnoid
haemorrhage and benign thunderclap headache were studied to delineate
the range of early features in these conditions. In this prospective
study, one of two observers interviewed 102 patients with acute severe headache by means of a standard questionnaire. The patients were alert
on admission and had no focal deficits. ASAH was subsequently diagnosed
in 42 patients, non-aneurysmal perimesencephalic haemorrhage (PMH) in
23 patients, and BTH in 37 patients. Headache developed almost
instantaneously in 50% of patients with ASAH, 35% of patients with
PMH, and 68% of patients with BTH and within 1 to 5 minutes in 19%,
35%, and 19%, respectively. Loss of consciousness was reported in
26% of patients with ASAH, 4% of patients with PMH and 16% of
patients with BTH, and transient focal symptoms in 33%, 9%, and 22%
respectively. Seizures and double vision had occurred only in ASAH.
Vomiting and physical exertion preceding the onset of headache were
more frequent in patients with ASAH (69% and 50%) and those with PMH
(83% and 39%) than in those with BTH (43% and 22%). Headache
developed almost instantaneously in only half the patients with
aneurysmal rupture and in two thirds of patients with benign
thunderclap headache. In patients with acute severe headache, female
sex, the presence of seizures, a history of loss of consciousness or
focal symptoms, vomiting, or exertion increases the probability of
ASAH, but these characteristics are of limited value in distinguishing
ASAH from BTH. Aneurysmal rupture should be considered even if focal
signs are absent and the headache starts within minutes.
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