Worst headache of your life? Could it be RCVS? (Reversible Cerebral Vasoconstriction Syndrome)

Imagine you're just at a loss, and suddenly, in less than a second, you get the worst headache you've ever had in your life... like a bolt of lightning striking your head. In medicine, we call this a "Thunderclap Headache." This is the most common and serious symptom of the condition we're talking about today, RCVS. A headache like this is a medical emergency that requires immediate treatment.

What is RCVS simply?

Simply put, Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a condition in which the blood vessels in your brain suddenly tighten and become blocked. It's like a water pipe being suddenly squeezed. When the blood vessels are blocked in this way, the brain doesn't get the amount of blood it needs. This is why you get that lightning-like headache I mentioned earlier.

The word "reversible" in the name of this condition means that it can be reversed with proper treatment . However, if left untreated, it can lead to serious conditions such as stroke or brain bleed. Sometimes, the symptoms are very similar to those of a migraine or stroke, making it difficult to distinguish between the two.

What are the symptoms of this condition?

All the symptoms of RCVS are caused by a disruption in the blood supply to the brain. Let's take a look at what these symptoms are.

What causes RCVS?

Our blood vessels have a layer of smooth muscle inside. These muscles control the flow of blood by contracting and relaxing. But sometimes these muscles suddenly spasm and contract too tightly. We call this ``vasospasm''. This is the main cause of RCVS.

There are a number of reasons why this condition (vasospasm) can occur.

Pregnancy and postpartum period

The most common cause of RCVS is pregnancy. The risk of this condition is highest during the first six weeks after delivery. This is believed to be due to sudden changes in hormone levels. This risk can occur even if you don't have conditions like preeclampsia during pregnancy.

Some medications and drug use

RCVS can be caused by certain medications and drugs that affect your circulatory system.

• Some medications for depression, especially those in the SSRIs group.
• Migraine medications (triptans and ergot-type drugs).
• Immune-suppressing drugs.
• Some medications for Parkinson's disease.
• Stimulants (amphetamines, cocaine, pseudoephedrine).
• Marijuana.
• Excessive consumption of caffeine and energy drinks.
• Nicotine patches.
• Drugs like `LSD` or `MDMA` (ecstasy).

Other medical conditions

Some medical conditions that affect the brain or blood circulation can also increase the risk of RCVS.

• Migraines: People with migraines are more likely to develop RCVS.
• Increased calcium levels in the blood (Hypercalcemia): Increased calcium levels can interfere with the function of the muscles in the blood vessels.
• Hormonal issues: The hormone estrogen in particular is suspected to be involved, which is why this disease is more common in women.
• Some hereditary conditions, such as ``Pheochromocytoma'' (a tumor that produces excess adrenaline hormone) and ``Porphyria'', may increase the risk.

What are the possible complications of RCVS?

In the past, doctors thought that RCVS was not a serious condition. But new research shows that it can sometimes cause complications. About 30% of people with RCVS may be left with some minor permanent disability (such as muscle weakness). About 8% may develop more serious long-term problems.

In addition, serious complications such as these can occur within a few days of the first symptoms:

• Ischemic stroke: Blockage of a blood vessel supplying blood to the brain.
• Intracerebral hemorrhage (SAH or another type of brain bleed): Bleeding between the brain and the skull.
• Seizures.

How do doctors find this?

A doctor uses several methods to diagnose this condition.

• A physical and neurological examination: Your reflexes, strength, and sensations are checked.
• Blood tests: Check for blood clotting problems, infections, and imbalances in salt levels.
• Imaging scans: This is the most important way to diagnose RCVS.

Imaging scans

These types of scans can "see" the inside of the head and brain. They can check for blocked blood vessels or reduced blood flow.

• Computed Tomography (CT) scans: In particular, CT angiograms can help to better assess the condition of blood vessels.
• Magnetic Resonance Imaging (MRI) scans: A special MRI scan called a Magnetic Resonance Angiogram (MRA) can also detect vasospasm in the blood vessels.
• Transcranial Doppler ultrasound: This can measure the speed of blood flow through the brain.

Usually, a CT scan is done first. Because it is quick. It can quickly determine if there is an emergency such as a stroke or bleeding. In a stroke, every second counts, so that speed is very important. Then, if necessary, an MRI scan is done to further confirm the blockage in the blood vessels.

What are the treatments for RCVS?

As the name suggests, RCVS is a highly treatable condition. Treatment has two primary goals.

1. If a cause can be found (e.g. a certain medication), remove that cause.

2. To relieve vasospasm (tightening) of blood vessels and restore them to normal.

The most common type of medication used to treat this condition (vasospasm) is calcium channel blockers (CCBs) . These medications work by blocking calcium from entering the muscle cells in the blood vessels. The muscles then relax, the blood vessels widen again, and blood flow returns to normal.

Very rarely, in some cases, treatment may be done using a procedure called ``endovascular''. This involves passing a very thin tube (catheter) through a blood vessel in the arm or leg to the blocked blood vessel in the brain, and then injecting medication or using something like a balloon to widen the vessel (angioplasty).

How can we hope for this situation?

Most people with RCVS (about 80% - 85%) recover completely without any long-term problems. So there is good hope for this. But the most important thing in this is to diagnose the disease early and start proper treatment.

Things you can do to prevent RCVS from recurring

Because it's not entirely clear why RCVS develops, it can't always be prevented. However, there are some things you can do to reduce your risk. Your doctor will give you more advice about this.

• If there are medications that are thought to have caused RCVS, stop them and avoid them in the future.
• Taking the medications prescribed by the doctor as prescribed and properly.
• Do not use any medication or drugs (especially stimulants and marijuana) without medical advice.
• Reduce or completely stop drinking caffeine and energy drinks.

When should you see a doctor and go to the ETU?

If you have RCVS, your doctor will tell you to keep coming to the clinic. It is very important to attend these appointments regularly. This way, your condition can be monitored and your treatment can be adjusted as needed.

When to go to the Emergency Treatment Unit (ETU) immediately:

If you have a thunderclap headache or stroke-like symptoms (e.g., weakness on one side of the body, difficulty speaking, vision changes) again, it is always a medical emergency. Don't wait until it's too late. Get to a hospital as soon as possible.