Investigators at centers in New Jersey report a 16-year-old girl with a history of anxiety, ADHD, and migraine, treated with several medications and presenting with 2 weeks of worsening headaches. CT was normal, but MRI angiography revealed cortical subarachnoid hemorrhage. CT angiography and follow-up digital subtraction angiography confirmed extensive vasoconstriction of small- to medium-sized cerebral arteries. Sertraline and methylphenidate were discontinued, and nifedipine (a calcium channel blocker) was introduced. Symptoms rapidly improved, and repeat CT angiography at 2 months showed no vasoconstriction. Call-Fleming syndrome, usually called “reversible cerebral vasoconstriction syndrome,” is an important cause of thunderclap headache in adults and should be considered in the pediatric population presenting with severe headache. [1]

COMMENT. Reversible cerebral vasoconstriction syndrome, sometimes called Call-Fleming syndrome [2] is rare in children but should be considered in the differential diagnosis of a child with a history of migraine and presentation with thunderclap headache. Many risk factors in addition to migraine are listed, including vasoactive drugs (triptans, amphetamines, ginseng, nicotine patch, oral contraceptives, diet pills, selective serotonin reuptake inhibitors), blood products, and trauma. The disorder is self-limiting, the headache resolving in 3 weeks and vasoconstriction resolving by 12 weeks. The majority has no residual symptoms and no recurrence of headaches, although stroke is a potential complication. Children treated with methylphenidate or amphetamines for ADHD and having a history of headache should be followed closely and the stimulant discontinued if headaches are persistent.