Reversible Cerebral Vasoconstriction Syndrome (RCVS) From SSRIs?

Our Psychosomatic Medicine Interest Group (PMIG) meeting was fascinating this week. It was about a phenomenon I don’t remember learning about when I was a medical student. Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a complicated phenomenon which occurs rarely, can lead to the thunderclap headache, which can be associated with selective serotonin reuptake inhibitors (SSRIs).

Dr. Andrea Weber, MD, MME gave us an excellent presentation about this topic. She’s one of our best residents in the combined Internal Medicine-Psychiatry residency program at The University of Iowa, and she raised some interesting questions for discussion. By the way, in case you didn’t know, MME stands for Master’s in Medical Education. The main reference was the review by Ducros and colleagues: Ducros, A. and Wolff, V. (2016), The Typical Thunderclap Headache of Reversible Cerebral Vasoconstriction Syndrome and its Various Triggers. Headache, 56: 657–673. doi:10.1111/head.12797.

It turns out that RCVS have been linked to SSRIs–and a large number of other triggers. I encourage anyone with an interest in the topic to read the review by Ducros and colleagues. While the most frequent triggers (among many others) seem to be sexual activity (just before or at orgasm), emotional upset and physical exertion, and use of adrenergic or serotonergic drugs, the authors point out that one U.S. study found no association of clincial worsening with serotonergic drugs.

On the other hand, thunderclap headache from RCVS has an alarming number of potential triggers including “…straining at stool, stressful or emotional situations, exertion, urinating without effort, coughing, sneezing, laughing, singing, contact with water, and sudden bending down,” according to the authors of the above-cited review. But no one is suggesting you give up karaoke and showering.

An interesting conundrum arises when I think about the association of thunderclap headache and RCVS with sexual activity and the sexual side effects of SSRIs. They can be associated with diminished libido and difficulty reaching orgasm. It’s just kind of an interesting irony.

One of the questions this issue poses is whether or not clinicians prescribing SSRIs should include this little known adverse effect in the risks and benefits discussions with patients and families. It could be a tough crossroads for a lot of people to navigate. What do you think?

In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.

 

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Comments

  1. I’ve been thinking about the sexual headache thing (why not?). Given the known sexual side effects of the SSRIs including the inability to reach orgasm and the one American study which showed no clinical worsening of thunderclap (TCH) headaches by SSRIs, could there be another FDA-approved indication for SSRIs?

    “Introducing Anorgasmarazzmatazzapine! Finally, a breakthrough for preventing the most common cause of thunderclap headache! Talk to your doctor or at least send her some money!”

    If singing can cause TCH and RCVS, would we get a break from people trying to sing the National Anthem at football games? “OhhhhsayyyOOOUUUCCCHHH!”

    If bending over can cause TCH/RCVS, why can’t we just remember what we learned in grade school–squat instead? It’s easier on the back, too.

    How about urinating without effort? Does that mean having an enlarged prostrate would confer a protective effect? I wonder if that’s a typo, of which there were several in the review paper.

    As far as straining at stool goes as a trigger for TCH/RCVS, isn’t it about time we had a little more C. diff infection? Hey, it’s Christmas!

    Contact with water–maybe those with Cannabis Hyperemesis Syndrome could have an incentive to at least cut down on the number of hot showers and baths they take to control nausea and vomiting, which reminds me: why is vomiting and retching not on the trigger list?

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