Recurrent, Severe Coital Headaches Associated With Bilateral Carotid Artery Aneurysms and the Effect of Endovascular Treatment

Abstract

Headaches are one of the most common chief complaints in the outpatient setting. Distinguishing between benign and life-threatening headaches can be difficult, particularly in the setting of a pre-existing history of headaches. Here, we present a 41-year-old female with a past medical history of migraines and uterine leiomyoma status post hysterectomy about nine months ago who presented to the clinic for severe coital headaches and worsening migraines starting eight months ago. Computer tomography angiogram (CTA) head and neck demonstrated bilateral para-ophthalmic internal carotid artery (ICA) aneurysms (right, 7.5, left 6 mm). A diagnostic cerebral angiogram (DSA) was subsequently done and confirmed the CTA findings. The patient underwent left and right flow-diverting stent placement two and four months later, respectively. One week after the right ICA stent placement, her headaches had improved to one to two times per week. At six months after the stent placement, she resumed her normal sex life and her migraines returned to baseline. Our case suggests that recurrent severe coital headaches are associated with bilateral carotid artery aneurysms. Thus, while assessing a patient with recurrent coital headaches, it is important to have a wide arsenal of differentials to rule out possibly catastrophic causes.

Keywords: carotid artery aneurysms; coital headache; flow diverting stent; headache associated with sexual activity; migraine headaches.

Figure 1. (A) Anterior view of the right internal carotid artery (ICA) aneurysm diagnostic cerebral angiogram (DSA); (B) Lateral view of left ICA aneurysm DSA

Figure 2. (A) Anterior view of left internal carotid artery (ICA) aneurysm diagnostic cerebral angiogram (DSA); (B) Lateral view of the left ICA aneurysm DSA

Figure 3. (A) 3D reconstruction of right internal carotid artery (ICA) aneurysm pre-treatment; (B) 3D reconstruction of right ICA immediately after flow-diverting stent placement; (C) 3D reconstruction of the right ICA six months after flow-diverting stent placement

Figure 4. (A) 3D reconstruction of the left ICA aneurysm before intervention; (B) 3D reconstruction of the left ICA immediately status post flow-diverting stent; (C) 3D reconstruction of the left ICA six months after flow-diverting stent placement