These ultraspicy peppers may either contain a unique vasoactive substance, or there is a dose-related effect of capsaicin concentration that can trigger RCVS. For reference, standard pepper spray contains around 2,000,000 to 5,000,000 SHU, ghost pepper 1,000,000 SHU, and jalapeno pepper 3500 SHU. The Carolina Reaper pepper boasts up to 2,200,000 SHU. The content of capsaicin, the compound that gives peppers their spicy taste, may be measured in Scoville heat units (SHU). Immediate vomiting after ingestion, not present in our case, may explain the immediate onset of headache in the other case. The later onset of headache is also unique to our case, which we hypothesize to result of vasoactive effects of the pepper predisposing the intracranial vascular endothelium towards the dysregulation of vascular tone seen in RCVS, with the onset of severe headache being precipitated by physical activity. Recurrent thunderclap headaches are associated with RCVS and are exacerbated by Valsalva, coughing, and physical activity. Transient hypertension during headache exacerbation in RCVS has been reported. The finding of hypertension was also unique to our case. Additional features in our case were the presence of acute infarct and focal cortical edema, both of which are associated with RCVS. In both cases, computed tomography head was negative for hemorrhage. In comparison to the other case, there is a similarity in the pattern of vessel narrowing in both the anterior and posterior circulation. Focal deficits at presentation are associated with a worse outcome. If a triggering substance is identified, withdrawal of the offending agent is paramount. Pathophysiology has been hypothesized to be a dysregulation of cerebral vascular tone and excessive sympathetic activity. RCVS may be idiopathic or may be triggered by a variety of causes including ingestion of vasoactive drugs, hypertensive crisis, catecholamine secreting tumors, and postpartum state. Resolution of the angiographic findings and symptoms indicate reversibility, but diagnosis may be made with characteristic clinical and imaging findings, as in our case. Initial angiographic imaging may be normal in the first 4 to 5 days of symptoms, which may be due to early involvement of small peripheral arterioles with progression proximally over time to involve the medium and larger arteries that are more easily visualized on imaging. Vascular imaging demonstrates segmental narrowing in multiple intracranial vessels. Subarachnoid or lobar hemorrhage, infarcts, and cerebral edema can occur with RCVS. Associated neurological deficits may or may not be present. Reversible cerebrovascular vasoconstriction syndromes are a group of conditions characterized by multifocal vascular narrowing and a clinical presentation of a sudden, severe headache. MR angiogram demonstrated multifocal segmental arterial narrowing involving the posterior cerebral arteries and superior cerebellar arteries, as well as the middle cerebral arteries ( Fig. Magnetic resonance imaging (MRI) brain revealed a focal acute infarct in the right cerebellar hemisphere and focal cortical edema along the right frontal convexity ( Fig. He received normal saline bolus, morphine, and divalproex sodium, which improved his pain to 5/10. He had no lateralizing symptoms or cerebellar signs on physical examination. He presented to the pediatric ED with a severe (10/10) bandlike headache described as the worst of his life. The headache improved but persisted, and 6 days after the initial ingestion, worsened with the development of nausea and vomiting. The following day, he again presented for headache to his pediatrician who diagnosed him with migraines and started prochlorperazine and diclofenac. Computed tomography head only showed sinus opacification, and he was discharged home on antibiotics for presumed sinusitis. After reading an article on the Internet about a case of thunderclap headache after ingestion of these peppers, he became concerned and presented to the emergency department (ED). His blood pressure at home was elevated at 167/95. Two days later, he developed an acute headache during football practice, which did not improve with acetaminophen. A 15-year-old healthy male ingested a Carolina Reaper pepper on a dare.
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