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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
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication.
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