Recumbent thunderclap headache in the postpartum period

Reversible cerebral vasoconstriction syndrome is characterized by thunderclap headache and reversible cerebral vasoconstriction, with or without other neurologic signs and symptoms.

A 33-year-old woman presented 13 days postpartum with a 4-day history of multiple thunderclap headaches while in the recumbent position, prompting her to attempt to sleep while standing or sitting. Cerebral angiogram demonstrated segmental cerebral artery vasoconstriction. Spinal fluid sampling excluded vasculitis, thereby confirming the diagnosis of reversible cerebral vasoconstriction syndrome. Treatment with a calcium channel antagonist rapidly attenuated her symptoms, and cerebral angiogram was normal at 3 months.

Thunderclap headache during the postpartum period precipitated by valsalva or recumbent positioning may indicate reversible cerebral vasoconstriction syndrome, which, if untreated, places a patient at risk for serious neurologic injury.