The patient was a woman in her 50s with a history of migraine and Raynaud’s disease. She had episodes of severe migraine that only partially responded to triptans, and worsened during pregnancy approximately 14 years prior, and also during the perimenopausal period approximately 2 years ago. After menopause, her migraines improved, occurred once a month, and responded well to triptans. She had elevated cholesterol. She had no known history of hypertension, diabetes mellitus, coronary artery disease, myocardial infarction, stroke, autoimmune disease or connective tissue disease. She was not on hormonal replacement therapy. She was a non-smoker with a moderately active lifestyle. She consumed 1–2 alcoholic drinks weekly and denied any illicit drug use. She had a strong family history of migraine. Three weeks before her death, she had an annual physical examination that did not reveal any new medical conditions. She was found dead in her bed at home and was brought to our institution for a postmortem examination. The case was declined by the medical examiner.

A postmortem blood toxicological analysis was negative for amphetamines, barbiturates, benzodiazepines, buprenorphine/metabolite, cannabinoids, cocaine/metabolites, fentanyl/acetyl fentanyl, methadone/metabolite, methamphetamine/3,4-methylenedioxy-N-methamphetamine, opiates, oxycodone/oxymorphone, phencyclidine, acetone, ethanol, isopropanol and methanol. A postmortem nasopharyngeal swab was negative for SARS-CoV-2 by PCR.

At autopsy, the decedent weighed 59 kg (130 lbs), was 62 inches (157 cm) in length and had a normal body mass index of 23.8 kg/m2. The external gross examination showed no significant abnormalities. The heart weighed 270 g (normal weight: 161–382 g based on height). The cardiac chambers were not dilated, and the atrial and ventricular wall thicknesses were within normal limits. The atrioventricular and semilunar valves were unremarkable. The epicardial coronary arteries had normal configuration, and the circulation was right dominant. There was no significant atherosclerosis, and the proximal coronary arteries were unremarkable. On cut …