6.7.3.1 Acute headache attributed to reversible cerebral vasoconstriction syndrome (RCVS)

Identification: Gender/Age: Female, 38 years.

History: Migraine without aura, use of selective serotonin reuptake inhibitor (SSRI) for depression.

Risk factors: Recent use of nasal decongestant (vasoconstrictor) and history of intense emotional stress.

History of Present Illness (HPI):
Main symptom: Sudden and severe headache ("worst of life"), thunderclap, 12 hours ago.

Pain characteristics:
Location: Diffuse, predominantly occipital.
Character: Explosive, pulsatile.
Intensity: 10/10.
Trigger: Reports having engaged in physical exertion (sexual activity) minutes before onset.

Associated symptoms: Nausea, photophobia, and dizziness.

Course: Continuous pain, no improvement with common analgesics.

Physical/Neurological Examination:
General: Conscious, distressed.

Neurological:
No motor or sensory deficits.
Normal reflexes, no meningeal signs.
Fundoscopy: No papilledema.

Complementary Exams:
Non-contrast Cranial CT: Normal (excluding subarachnoid hemorrhage).
Cranial MR Angiography: Multifocal segmental narrowings ("string of beads") of cerebral arteries, compatible with RCVS.
CSF (lumbar puncture): Normal pressure, no pleocytosis or red blood cells.