6.5.2 Post-endarterectomy headache

History: A 72-year-old woman with hypertension and diabetes underwent right carotid endarterectomy 36 hours ago due to severe asymptomatic stenosis (>80%). She reports an intense headache (8/10) in the right hemicranium, with a pulsatile character, which began approximately 12 hours after surgery. She notes worsening of the pain with postural changes and coughing. She denies photophobia, phonophobia, or vomiting, but experiences mild nausea.

Physical/Neurological Examination: Conscious, oriented, without motor or sensory deficits. Pupils are isocoric and reactive to light. No neck stiffness or other meningeal signs. Symmetrical carotid pulses, without bruits. Surgical wound without signs of inflammation.

Investigation:

Non-contrast cranial CT: No acute changes (excluding hematoma, edema, or ischemia).

Transcranial Doppler: Increased blood flow in the right middle cerebral artery, but no criteria for cerebral hyperperfusion syndrome.

Blood pressure: Controlled (140/85 mmHg), without hypertensive peaks.