Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap
headache (TCH) and cerebral vasospasm. Selective serotonin reuptake inhibitors (SSRIs) have been
strongly associated with RCVS although the mechanism is not clear. We describe a case of a patient who developed RCVS as a result of ingesting several tyramine-rich foods while on an SSRI.

A 54-year-old woman presented with a TCH and vomiting. She was on fluoxetine
since age 20. Before symptoms onset, she ate over-ripened avocados, aged-parmesan cheese, and
packet soup, with papaya enzymes to aid with digestion.

Computed tomography (CT) of the head revealed an acute subarachnoid hemorrhage (SAH) in the left
parasagittal parietal cortical sulcus. CT angiography showed multifocal vessel stenosis involving bilateral posterior and anterior inferior cerebellar arteries, right superior cerebellar artery, right posterior communicating and cerebral arteries, middle and anterior cerebral arteries. Work-up for primary angiitis of the central nervous system (PACNS) was unremarkable.

Patient’s symptoms resolved with use of oral acetaminophen, antihypertensive agents and
discontinuation of fluoxetine. Six weeks from initial presentation, magnetic resonance angiography of
the head revealed resolution of vasospasm. She was diagnosed with RCVS as a result of eating
tyramine-rich food combined with an SSRI.

Our case report describes a patient who developed RCVS secondary to ingestion of tyramine-rich diet while on SSRIs. Her symptoms resolved after discontinuation of fluoxetine and dietary
modifications.