Normalization of blood pressure is recommended for this patient with reversible cerebral vasoconstriction syndrome (RCVS). This condition most commonly presents with thunderclap headaches that recur over several days or weeks. Thunderclap attacks may occur spontaneously or be triggered by bathing, exertion, or Valsalva maneuvers. The headaches may be complicated by focal neurologic deficits with corresponding areas of stroke, parenchymal hemorrhage, or edema visible on neuroimaging studies. The cerebrospinal fluid is typically normal or near normal. Cerebral angiographic studies reveal multifocal areas of vasospasm without evidence of aneurysm. RCVS can occur without an identifiable cause or may be associated with preeclampsia or eclampsia, exposure to certain medications (sympathomimetic agents, ergots, triptans) or blood products (transfused erythrocytes, immune globulin), or catecholamine-secreting tumors. Medications or illicit drugs are associated in up to 40% of affected patients, and women with the syndrome outnumber men at a ratio of 6:1. Migraine may be a predisposing factor. Transient neurologic deficits occur in 30% of patients with RCVS, and 10% may experience persistent deficits from parenchymal damage caused by ischemic or hemorrhagic infarctions.
No clinical trial data are available on which to base therapeutic recommendations. Conservative management, supported by expert consensus, includes headache control with analgesics, careful monitoring of blood pressure to maintain normotensive goals, and serial neurologic examinations.
Primary stabbing headache is a form of benign abrupt-onset headache that may respond to indomethacin. This type of headache typically lasts seconds, not 30 minutes as with this patient. Primary stabbing headache also occurs without visual blurring, focal numbness, or other neurologic symptoms. Although indomethacin is appropriate for treating several additional primary headache syndromes, such as chronic paroxysmal hemicrania, evidence does not support its effectiveness in RCVS.
Because reversible vasoconstriction and not thrombosis is the responsible mechanism for RCVS, tissue plasminogen activator is not indicated in this patient. The use of calcium channel antagonists, such as nimodipine or verapamil, is more appropriate.
No evidence suggests that anticoagulants, such as warfarin, or antiplatelet agents, such as aspirin, affect stroke risk or outcomes in RCVS. The mechanism of cerebral infarction, when present, is likely related to cerebral artery vasospasm and not thrombosis. Given this pathophysiology and the relatively high rate of hemorrhagic infarction in RCVS, antiplatelet or antithrombotic therapy has no role in disease management.