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Looking at “Thunderclap headache(TCH)” differently?

      The term “thunderclap headache” (TCH) was first coined in 1986 by Day and Raskin to describe the type of headache that was the presenting feature of an underlying unruptured cerebral aneurysm. The term is now well established to describe the abrupt onset headache seen with many other conditions. An essential to label an acute headache as “TCH” and differentiate it from other “sudden onset, severe headaches” is the arbitrary time frame of 1 min from onset to peak intensity for “TCH.” This arbitrary time frame that is essential to define “TCH,” is very difficult to assess in practice and is usually done on a presumptive subjective basis. As a result, even those “sudden onset, severe headaches” that do not strictly fulfill the definition criteria are also labeled as “TCH” and investigated with the same speed and in the same sequence and managed based on the underlying cause. There is also a need today for modification of the current investigation protocol for TCH. This proposal for “a change in practice methodology” is essentially based on (1) the fact that in the last two decades, we now have evidence for many more entities other than just subarachnoid hemorrhage that can present as “TCH” or “sudden onset, severe headache” and (2) evidence from literature shows that advances in imaging technology using higher magnet strength, better contrast, and newer acquisition sequences will result in showing up other underlying etiologies that have been described more recently. It is therefore time now, in our opinion, to discard current theoretical time frames and modify the investigation protocol from “lumbar puncture (LP) first” to “LP last!”.
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