Verapamil-responsive coital cephalalgia as reversible cerebral vasoconstriction prodrome

Autor: Nicholas H. Chia, Timothy Kleinig
Rok vydání: 2014
Předmět:
Zdroj: Journal of Neurology. 261:1641-1643
ISSN: 1432-1459
0340-5354
DOI: 10.1007/s00415-014-7417-5
Popis: A 50-year-old woman suffered an excruciating thunderclap headache while defecating. She reported 13 years of coital cephalalgia (CC) with thunderclap occipital throbbing headaches occurring at orgasm, rated as 10/10 in severity. Peak intensity lasted for 10 min with resolution over the next 20. For the last 3 years, similar but milder headaches had rarely occurred with micturition. She did not use overthe-counter sympathomimetics, alcohol or illicit drugs. In the week prior, she noted escalation of her CC with headaches lasting hours instead of minutes. The headache leading to presentation was more severe and prolonged than previous coital headaches, but otherwise identical in character. Vital signs, including blood pressure were normal and there were no neurological deficits. Plain head computed tomography (CT) and lumbar puncture were normal. She continued to experience milder episodes with micturition and postural changes. Sexual intercourse was avoided. A week later, she had another severe headache during micturition. CT angiography demonstrated numerous areas of segmental narrowing and dilatation (Fig. 1a– c). A provisional diagnosis of reversible cerebral vasoconstriction (RCVS) was made. Nimodipine 60 mg 4-hourly yielded complete resolution of her headaches. Eleven days later, this was changed to slow-release nifedipine 120 mg daily, however, CC symptoms recurred. Subsequently, 360 mg controlled-release verapamil proved effective. Vessel abnormalities resolved on CT angiogram 3 months later (Fig. 1d). Six months post-presentation verapamil was reduced to 180 mg, but 360 mg was resumed after an explosive headache within 24 h. A year later, she remains free of headaches and side effects. RCVS is characterised by severe thunderclap headache and segmental vasoconstriction which resolves within 3 months [1]. Headaches are usually recurrent and may be associated with acute neurological deficits. Triggers include coitus, defecation, micturition, physical exertion or emotion [2, 3]. Similar headaches occurring at orgasm are a common CC phenotype, and these may demonstrate cerebral vasoconstriction [4, 5]. RCVS headaches may be related to abnormalities in cerebral vascular autoregulation, sympathetic activity and endothelial function [6]. Hypertensive surges are observed in one-third of patients, but a causal relationship with cerebral vasospasm is unclear [6]. Pre-eclampsia and posterior reversible encephalopathy syndrome demonstrate endothelial dysfunction, and their occasional co-existence with RCVS suggests deranged endothelial responses contribute to the pathophysiology [6]. RCVS is rare: Taiwanese and French headache centres reported incidences of 0.5 and 0.3 %, respectively [2, 3]. The larger French cohort identified secondary causes in 63 % of cases, most commonly pregnancy, selective serotonin reuptake inhibitors and nasal decongestants [2, 3]. Cannabis and acute alcohol intoxication have been reported as precipitants [3]. N. H. Chia The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA 5011, Australia e-mail: Nicholas.Chia@health.sa.gov.au
Databáze: OpenAIRE
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