TLDR RCVS should be considered in thunderclap headaches, and MRA and DSA are better for diagnosis than CT angiogram.
A 30-year-old male experienced thunderclap headaches triggered by free-diving and intense exercise, with a history of vaping and topical finasteride use. Despite normal blood tests and CSF analysis, MRA and DSA revealed vasoconstriction in the basilar artery, which resolved with milrinone and verapamil treatment. The case highlights the importance of considering RCVS in thunderclap headaches and suggests MRA and DSA as more sensitive imaging modalities than CT angiogram for diagnosing RCVS.
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