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Case Report
Abstract
OXYMETAZOLINE IS A SYMPATHOMIMETIC amine found in over-the-counter nasal decongestants. We report a case of chronic use of nasal oxymetazoline associated with thunderclap headache due to reversible segmental intracranial vasoconstriction.
CMAJ 2004;171(6):593-4
A 31-year-old woman had sudden onset of global headache at 1 pm when she was resting that she characterized as the "worst of her life," rating the pain as 10/10. Associated symptoms included nausea, vomiting, sonophobia and photophobia. The headache waxed and waned over the next 4 days, and on day 4 the patient presented to the emergency department in a community hospital. Her blood pressure, findings on neurological examination and initial CT scan were normal. Her past medical history included hiatal hernia, cigarette smoking and remote use of marijuana (she denied any other illicit drugs), and she was taking sertraline, peptobismol, lansoprazole and domperidone. A lumbar puncture revealed normal cerebrospinal fluid with no xanthochromia. The opening pressure in the seated position was 37 cm H2O. She was transferred to our hospital, and CT venography was performed. It revealed no venous sinus thrombosis, but multifocal vessel irregularities in both the anterior and posterior arterial circulations were observed. Cerebral angiography confirmed focal areas of vasospasm in the internal carotid circulations bilaterally as well as in the vertebrobasilar system (Fig. 1A, B, C). Results of hematologic and serologic investigations were negative for signs of systemic infection, inflammation or vasculitis.
The patient had been using Afrin, a nasal spray that contains oxymetazoline, regularly for the previous 6 months. Although she was using the medication at recommended daily dosages...