World's Hottest Chili Pepper Ignites Severe Thunderclap Headache

Damian McNamara

April 11, 2018

In the first reported case of its kind, a 34-year-old man competing in a chili pepper–eating contest experienced a sudden thunderclap headache after ingesting a single "Carolina Reaper," which is widely considered the world's hottest chili pepper.

After experiencing dry heaves without vomiting, the man developed intense neck and occipital pain that become holocephalic. The excruciating pain drove him to seek emergency department care. He had at least two more episodes of brief thunderclap headache over the ensuing days.

Initial diagnostic tests came back negative. His urine drug screen and noncontrast head and neck computed tomography (CT) scans were unremarkable. He had no neurologic deficits, and his blood pressure was 134/69 mm Hg.

Although CT angiography did not show an aneurysm, it did reveal a surprise. Doctors detected multifocal luminal narrowing in his left supraclinoid internal carotid artery, M1 segment of bilateral middle cerebral arteries, and P1 segments of bilateral posterior cerebral arteries —  a finding consistent with vasospasm.

"A few cases have been reported regarding coronary vasospasm and myocardial infarction caused by ingestion of cayenne pepper and use of topical capsaicin patch," Kulothungan Gunasekaran, MD, from the Division of Hospital Medicine at Henry Ford Hospital in Detroit, Michigan, told Medscape Medical News.

"To the best of our knowledge after extensive literature search, our case is the first to report cerebral vasospasm leading to reversible cerebral vasoconstriction syndrome [RCVS] after ingestion of the Carolina Reaper," he added.

The case was reported online April 9 in BMJ Case Reports.

 More Cases on the Way?

"After ruling out the common causes, including subarachnoid hemorrhage and cerebral vasculitis, neurologists should consider RCVS in the differential diagnosis of thunderclap headaches in those with a history of ingestion of vasoactive substances like hot chili peppers," he said. "Taking a thorough history including dietary habits plays a very important role in diagnosis and management of these patients." 

Capsaicin is the active component in the Carolina Reaper. The vasoactive substance may have altered control of cerebrovascular tone, spurring cerebral vasoconstriction that potentially led to RCVS in this case. RCVS more commonly involves reactions to prescription medications or arises secondary to illicit drug use.

Ergotamine, selective serotonin reuptake inhibitors, α-sympathomimetic decongestants, and triptans are among the medications implicated in cases of the syndrome.  

Although the first such report in the literature, Gunasekaran noted that "with new advances in neuroimaging like cerebral angiography and increased use of vasoactive substances, physicians may encounter a growing number of patients with RCVS spectrum."

"Unfortunately, we don't have information regarding the patient's performance in the chili-eating contest," he said.

The primary approach to treating RCVS is removal of the offending substance and supportive care, which worked in this case. Follow-up CT angiography 5 weeks after initial hospitalization revealed resolution of the vasoconstriction. "In addition, several months later, the patient followed up in the clinic without any recurrence or new symptoms"

Gunasekaran has disclosed no relevant financial relationships.

BMJ Case Rep. Published online April 9, 2018. Abstract

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