When a patient presents with thunderclap or recurrent sudden severe headaches and subarachnoid haemorrhage has been excluded, ask specifically about serotonergic and vasoactive exposures in the preceding weeks: triptans, ergots, SSRIs and SNRIs, nasal decongestants, stimulants, cannabis and recent postpartum state.
Patients rarely volunteer decongestant sprays or cannabis unless asked. Stopping the trigger is part of treatment, and a triptan for the headache itself should be avoided.
- Triptans and ergots.
- SSRIs and SNRIs.
- Nasal decongestants and stimulants.
- Cannabis.
- Postpartum period.
Why it matters
The trigger drug is often unreported and keeps the vasoconstriction going.
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