Thunderclap headache is well recognized as key feature of potentially life-threatening underlying intracranial pathologies, but recognition of this entity in autonomic dysreflexia (AD) during chronic phase of spinal cord injury (SCI) can be challenging and requires high index of suspicion. 

AD is defined as episodic hypertension or hypotension with baroreflex-mediated bradycardia or tachycardia, initiated by unmodulated sympathetic reflexes in decentralized cord, triggered by bladder distention, bowel impaction, bone fractures, deep vein thrombosis, or pressure sores; in patients with SCI especially above T6. Majority of patients with AD presents with headache, and despite broad clinical presentation, one of the most important patterns to recognize, is the thunderclap headache characterized by sudden onset of pounding/throbbing headache reaching quickly maximal intensity. Other symptoms of AD include bradycardia, tachycardia, diaphoresis, flushing, pale skin with piloerection above level of injury, visual disturbances, anxiety, nausea/vomiting.

Case report and literature review.

42-year-old woman with history of migraine, anxiety, chronic pain, neuromyelitis optica with residual absent of peripheral vision in the right eye; tetraparesis, neurogenic bladder, and neurogenic bowel with diverting colostomy, secondary to multiple cervical and thoracic chronic demyelinating lesions, presented with thunderclap headache and facial flushing followed by tachycardia with heart rate of 137 beats/min and hypotension with blood pressure of 72/54 mm Hg secondary to AD. She was found to have urinary tract infection, right leg cellulitis and deep vein thrombosis in the left common femoral vein. Workup including head CT, brain MRI, and MRV ruled out intracranial pathology.  Thunderclap headache resolved with management of AD. 

Not applicable

AD is a potentially life-threatening cardiovascular complication of SCI secondary to neuromyelitis optica. Greater awareness of thunderclap headache associated with autonomic disturbances as clinical manifestation of AD in this patient population is crucial for early diagnosis and proper adequate treatment to prevent severe complications or even death.