Images In...

Thunderclap headache after take off of a commercial jet airplane

Ana M Garcia¹, Rocio E Garcia-Cobos², Natividad Gomez-Ruiz³

¹ Hospital Clinico Universitario San Carlos, Stroke Unit, Avda Martin Lagos, s/n, Madrid, Spain
² Hospital Clinico Universitario San Carlos, Neurology, Avda Martin Lagos, Madrid 28040, Spain
³ Hospital Clinico Universitario San Carlos, Diagnostic Radiology, Avda Martin Lagos, Madrid 28040, Spain

Correspondence to:
Ana M Garcia, amgarciagarcia{at}gmail.com

An adult patient presented with an acute and maximum in intensity at onset frontal headache that began 30 min after take off of a commercial jet airplane 1 week previously. The patient’s medical history was unremarkable. Physical examination and ophthalmoscopy were normal. Differential diagnosis included subarachnoid haemorrhage, cervical artery dissection, cerebral venous thrombosis, spontaneous intracranial hypotension, pituitary apoplexy, retroclival haematoma and reversible cerebral vasoconstriction syndrome. An emergency magnetic resonance imaging (MRI) was performed (see figs 1 and 2). A mass in the frontal sinus was found. Other possible headache causes were excluded as there were no additional findings on MRI. As axial T1-weighted images showed a normal wall artery, and flow-related enhancement of carotid and vertebral arteries was symmetric on MR angiography, cervical artery dissection was ruled out. The mass in the frontal sinus was thought to represent a haematoma, with the bleeding being a result of barotrauma. Rapid changes in ambient pressure in an obstructed sinus result in a vacuum effect.¹ If severe, "the squeeze" can present as a sudden and intense headache. According to severity, Weissman² suggested a clinical grading of sinus barotrauma. Grade III is the most severe situation, and the patient complains of abrupt and intense pain that can last >24 h. Frontal sinus barotrauma should be considered as a cause of thunderclap headache.³

View this figure (75K): in this window | in a new window | PowerPoint for Teaching   Figure 1 (A) Sagital view T1-weighted and (B) axial view FLAIR (fluid attenuated inversion recovery)-weighted magnetic resonance images obtained in the emergency room. A round frontal mass is shown. The intensity corresponds to a 7 day history.

 

View this figure (45K): in this window | in a new window | PowerPoint for Teaching   Figure 2 Axial (A) and lateral (B) view of 3D time-of-flight (TOF)-weighted magnetic resonance imaging. No aneurysms or arteriovenous malformations are seen.

 

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication.

1. Segev, Y, Landsberg, R, & Fliss, DM. MR imaging appearance of frontal sinus barotrauma. AJNR Am J Neuroradiol 2003; 24: 346–7.[Abstract/Free Full Text]
2. Weissman, B, Green, RS, & Roberts, PT. Frontal sinus barotrauma. Laryngoscope 1972; 82: 2160–8.[CrossRef][Medline]
3. Schwedt, TJ, Matharu, MS, & Dodick, DW. Thunderclap headache. Lancet Neurol 2006; 5: 621–31.[CrossRef][Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?