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Thunderclap Headache: Every Second Counts in Brain Emergencies

Cedars-Sinai Thunderclap Headache patient Julie Hunter walking her dog at the beach on sunset.

As the world shut down during the COVID-19 pandemic, Julie Hunter's life expanded. The 58-year-old  married for the first time after losing her longtime partner a few years prior. With her husband, Dan, came three adult children, a bichon frise named Elvis and a new home—which closed escrow the day of their Beverly Hills courthouse wedding. It was a fresh start.

Julie, a professional psychic, embraced the "whirlwind of wonderful" right away and began settling in.

"There's no such thing as overreacting to a possible stroke symptom. In cases of stroke, every second counts."

"I live my life being very open to people," she says.

In March 2022, Julie was decorating her new house—hot-gluing flowers onto a lampshade—when, out of nowhere, she felt something unusual.

"I didn't recognize it as pain immediately," she says. 

For about a minute, her head was pulsing. Then it hurt—badly.

A medical emergency

Because of Julie's history, she assumed it was a migraine. But lying down only made her nauseous. Over-the-counter cold medications and migraine treatments (triptans) didn't help either. She made two trips to urgent care, where she was given anti-nausea pills for the possible migraine.

After two days, the pain subsided a little, and Julie thought she was in the clear. Then her symptoms came back with a vengeance. At her third urgent care visit—this one a week later—the doctors told her to head to the emergency room.

"I thought, 'Is anyone really going to pay attention to me having a stupid headache?'" she says. 

By the time she arrived at the Cedars-Sinai Emergency Department, she was so weak she had to be transported in a wheelchair.

Cedars-Sinai neurologist Carlin Rachel E. Carlin, MD.

Rachel E. Carlin, MD

Cedars-Sinai neurologist Dr. Rachel Carlin, who treated Julie, says many people aren't aware a headache can be a medical emergency. 

"Some people don't want to come into the ER because they feel like they're bothering someone or being dramatic, or they're embarrassed," she says.

Thunderclap headaches like Julie's come on quickly—usually in under 60 seconds—and are the worst headaches of your life, Dr. Carlin explains. They're a major warning sign of hemorrhagic stroke, as well as other life-threatening conditions such as severely high blood pressure or even meningitis.

"There's no such thing as overreacting to a possible stroke symptom," she says. 

She urges anyone experiencing thunderclap headaches to call 911 immediately.

"In cases of stroke, every second counts," she stresses.

Diagnosing a hemorrhagic stroke

Cedars-Sinai patient Julie Hunter in the hospital giving a thumbs up after experiencing a thunderclap headache.

Julie stayed at Cedars-Sinai for four days while the stroke team conducted a series of diagnostic tests on her head, neck and cerebrospinal fluid.  

Neurologists discovered a coating of blood had pooled around the outer layer of her brain, known as a subarachnoid hemorrhage. About 13% of strokes are hemorrhagic, according to the American Stroke Association. 

With an angiogram, the doctors looked closer at Julie's vascular network and found multiple blood vessels in spasm.

"The brain doesn't like the altered blood flow dynamic when vessels spasm, so it can cause it to bleed," Dr. Carlin explains.

Vasculitis, inflammation that can trigger vasospasms, was ruled out in a follow-up spinal tap.

Finding the root cause

The culprit for Julie's painful headaches and bleeding? Reversible cerebral vasoconstriction syndrome (RCVS). The underdiagnosed disorder squeezes blood vessels in the brain and forces arteries to narrow. More than 30% of stroke patients develop subarachnoid hemorrhage. 

RCVS can cut off blood supply and oxygen to the brain, making both hemorrhagic strokes (caused by bleeding) and ischemic strokes (caused by lack of oxygen) more likely.

"Blood vessels might clamp down so much that you can't get blood flow to the area of the brain the vessel was supposed to be feeding," Dr. Carlin adds.

The exact cause of RCVS is unclear, but there are known risk factors, including head trauma, binge drinking, heavy, daily marijuana use, certain antidepressants, nasal decongestants and hormone supplementation.

While in menopause, Julie had been taking hormones for hot flashes. And her efforts to treat her thunderclap headaches with cold and migraine medicines may have unknowingly made her RCVS worse, Dr. Carlin adds.

Patient Julie Hunter in treatment for thunderclap headache.

Caught in time

With appropriate care, the vasospasm in RCVS can be reversed, usually within three months.

Julie's providers advised her to discontinue the RCVS-linked medications and prescribed calcium channel blockers, the standard of care for the condition. The blood pressure treatment, Nimodipine, helps tightened blood vessels relax. 

She'll take the drug until a repeat angiogram shows her vascular system has returned to normal. Within a few months to a year, lingering symptoms such as headaches may resolve, Dr. Carlin says, although some patients develop chronic headaches. Recurrence of RCVS is uncommon.

Because Julie's brain bleed was stable and caught in time, the stroke didn't permanently impair her physical functioning or require rehabilitation for speech or movement. 

"If Julie had not come in, it definitely could have progressed and resulted in further brain injury," Dr. Carlin cautions.

Another new beginning

In the wake of her diagnosis, Julie struggled with daily headaches, exhaustion and dizziness. Because the RCVS treatment lowered her blood pressure, she felt too lightheaded to drive or exercise. And she had to rest much more than she was used to. 

Family and close friends stepped in. Dan and Julie's best friend took turns driving. Her stepson surprised her by cooking. Julie's sister and 85-year-old mom offered shoulders to lean on. 

Independent and used to caring for other people, Julie had to learn to accept their help.

The "greater heart exchange" deepened her relationships, she says.

Paying attention to wellbeing

Patient Julie Hunter post-treatment for subarachnoid hemorrhage and thunderclap headache.

Even though most of her energy has returned—and she heals more every day—Julie still naps regularly. The rest aids blood vessel repair and allows her to stay balanced emotionally. 

"It's helped me find a different cadence," she reflects.

A psychic for nearly 30 years, Julie wondered why she didn't sense that the ache was more than a migraine. But she now understands she didn't have her normal abilities while she was ill: Pain overrides all the senses, "even the psychic ones," she's learned.

Two months on, she has gone back to work and feels the stroke opened up a new way to care for sick clients. She looks closer and asks, 'Is there something else that needs to happen?'"

"When you're not well," she says, "you don't always make the best decisions."