Thunderclap Headache Associated With a Nonhemorrhagic Anaplastic Oligodendroglioma

Randolph W. Evans, MD

In This Article


Although Day and Raskin[1] initially coined the term thunderclap headache to refer to the headache associated with an unruptured aneurysm, the most common secondary cause is subarachnoid hemorrhage. Other secondary causes include cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, ischemic stroke, acute hypertensive crisis, reversible cerebral vasoconstrictive syndrome, third ventricle colloid cyst, intracranial infection, and complicated paranasal sinusitis.[2,3,4]

Hemorrhage into a pituitary adenoma or a colloid cyst of the third ventricle also can produce a thunderclap headache. Cough headaches related to middle cranial fossa or posterior fossa meningiomas, pinealoma, chromophobe adenoma, and a medulloblastoma have been reported, as well as exertional headaches associated with brain metastases, and sex headaches caused by hemorrhage into a cerebral tumor.[5] To my knowledge, this is the first reported case of a thunderclap headache associated with a nonhemorrhagic glioma.

In almost two-thirds of patients with oligodendrogliomas, the first symptom is seizures, as in this case, and up to one-third experience headache.[6] Kunkle and colleagues[7] postulated 4 mechanisms of headache pain associated with brain tumors including: traction of the veins draining into the large venous sinuses with resulting displacement; traction on the middle meningeal artery; traction on the major arteries at the base of the brain; and direct pressure on cranial nerves with afferent pain fibers from the head. Depending on the degree of brain displacement and the presence of hydrocephalus, which might cause traction on distant structures, the pain could be localized or distant.

Although the role of increased intracranial pressure in the generation of headache is debatable, a sudden increase in intracranial pressure (plateau waves) might cause a thunderclap headache as in this case.[8,9] Alternatively, this patient with a glioma may have had an unrelated primary thunderclap headache. A causal relationship may be further supported if similar patients with thunderclap headaches are reported in the literature.


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