The 68th
Scientific Meeting
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| 19S-005 |
Reversible cerebral vasoconstriction with thunderclap headache: A case report
순천향대학교 의과대학 천안 병원 마취통증의학교실
*Introduction
Reversible cerebral vasoconstriction syndrome (RCVS) is often accompanied by thunderclap headaches. Although symptoms usually resolve spontaneously within 2 months, it can cause fatal complications, such as cerebral hemorrhage, and is difficult to differentiate from a migraine and other headaches on the basis of symptoms and Imaging study.
*Case Report
A 42-year-old female patient complained of a severe throbbing headache with a Numeric Rating Scale (NRS) score of 10 after defecation. The pain subsided temporarily after treatment with diclofenac 75mg and Tridol 50mg propacetamol 1g, but the headache returned upon defecation; soon after, the patient complained again of regular headaches at 4defecation. Brain computed tomography (CT) and head and neck magnetic resonance angiography, performed during a headache episode, revealed no specific neurological findings. Blood analysis was also normal. Head and neck CT angiography(Figure 1.), performed one month after the start of the headaches, revealed RCVS. Treatment commenced with pregabalin (150 mg), oxycodone HCl/naloxone (10/5 mg), Alpram (0.5 mg), milnacipran (25 mg), and frovatriptan 25mg, but there was no improvement in the headaches. The patient received bilateral trigger point injections (TPI) in the temporal muscles on four occasions at the pain clinic. Medication showed no effect, but after the patient received four sessions of bilateral TPI in the temporal muscles her NRS score eventually decreased from 10 to 2. The patient is currently continuing medication while still experiencing headaches at reduced intensities.
*Conclusion
RCVS is not a commonly seen disease and is difficult to diagnose. but because it can cause fatal complications, such as cerebral hemorrhage or cerebral infarction, continual monitoring is essential. Thunderclap headache is likely to be a red flag and necessitates immediate neurological and radiological examination. The vasoconstrictive drugs used in general migraine aggravate RCVS even further, and so it is important to differentiate it from symptoms of migraine. In cases such as this one, where TPI in the bilateral temporalis muscles alleviates symptoms, it is likely that the headache is also accompanied by myofascial pain syndrome in the temporalis muscle, and so diagnostic treatment using this method should also be considered.
Reversible cerebral vasoconstriction syndrome (RCVS) is often accompanied by thunderclap headaches. Although symptoms usually resolve spontaneously within 2 months, it can cause fatal complications, such as cerebral hemorrhage, and is difficult to differentiate from a migraine and other headaches on the basis of symptoms and Imaging study.
*Case Report
A 42-year-old female patient complained of a severe throbbing headache with a Numeric Rating Scale (NRS) score of 10 after defecation. The pain subsided temporarily after treatment with diclofenac 75mg and Tridol 50mg propacetamol 1g, but the headache returned upon defecation; soon after, the patient complained again of regular headaches at 4defecation. Brain computed tomography (CT) and head and neck magnetic resonance angiography, performed during a headache episode, revealed no specific neurological findings. Blood analysis was also normal. Head and neck CT angiography(Figure 1.), performed one month after the start of the headaches, revealed RCVS. Treatment commenced with pregabalin (150 mg), oxycodone HCl/naloxone (10/5 mg), Alpram (0.5 mg), milnacipran (25 mg), and frovatriptan 25mg, but there was no improvement in the headaches. The patient received bilateral trigger point injections (TPI) in the temporal muscles on four occasions at the pain clinic. Medication showed no effect, but after the patient received four sessions of bilateral TPI in the temporal muscles her NRS score eventually decreased from 10 to 2. The patient is currently continuing medication while still experiencing headaches at reduced intensities.
*Conclusion
RCVS is not a commonly seen disease and is difficult to diagnose. but because it can cause fatal complications, such as cerebral hemorrhage or cerebral infarction, continual monitoring is essential. Thunderclap headache is likely to be a red flag and necessitates immediate neurological and radiological examination. The vasoconstrictive drugs used in general migraine aggravate RCVS even further, and so it is important to differentiate it from symptoms of migraine. In cases such as this one, where TPI in the bilateral temporalis muscles alleviates symptoms, it is likely that the headache is also accompanied by myofascial pain syndrome in the temporalis muscle, and so diagnostic treatment using this method should also be considered.
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