6.7.3.3 Persistent headache attributed to past reversible cerebral vasoconstriction syndrome (RCVS)

Identification: Female, 42 years old, with no significant previous comorbidities. Past history of episodic migraine without aura. Clinical History: The patient sought emergency care six months ago due to a sudden onset thunderclap headache of severe intensity, without signs of infection or severe arterial hypertension. She was diagnosed with Reversible Cerebral Vasoconstriction Syndrome (RCVS) after magnetic resonance angiography revealed the classic pattern of multifocal segmental constriction (string of beads). There were no persistent neurological deficits or signs of intracranial bleeding. Conservative treatment was initiated, with the suspension of potential precipitating factors (use of nasal decongestants, caffeine, and emotional stress crises), in addition to calcium channel blockers. After three months, a follow-up angiography showed complete normalization of the cerebral arteries, confirming the reversibility of RCVS. Evolution: However, the patient continued to experience chronic headaches of moderate to severe intensity, without the characteristics of the initial thunderclap headache. The pain occurred daily, diffusely located in the occipital and parietal regions, worsening with exertion and occasionally accompanied by mild photophobia. The use of analgesics was necessary sporadically, without medication overuse. Complementary exams: Follow-up angiography: normal, without signs of residual vasospasm. Brain magnetic resonance imaging: no signs of residual infarcts or hemorrhages. Lumbar puncture: normal, without signs of infection or intracranial hypertension.