I have been considering no Local Leader but for me no fast travel is mandatory because the adventure is always on the road, otherwise it gets too easy to follow the railroady plot and speed thru the replay.
No Local Leader is a tough price to pay if you cannot zip back to home easily since workshops will not be connected with caravans, it really is essential to a no Fast Travel game since most settlements are not supportable with enough local/nearby junk and walking across the map after every raid seams infeasible. Only if you truly are doing a no workshops at all, meaning only found gear, food and chems no crafting/mods at all. Maybe I will try in a future reroll.
What I am doing is using a d8 die to spend SPECIALs at the start. (An 8 is either a reroll or free choice). My last PC rolled 7 on CHA so I of course went for Local Leader so have not tried without it yet. While each SPECIAL is theoretically equal chance this does not actually make balanced SPECIALs - as that is only true with infinite rolls, with only 21 rolls you will get unbalanced PC which can force you into unique playstyles. The same idea could be done with Perk upgrades, roll for it.
I am also ignoring the compass that somehow finds nearby things my character cannot see. Only if an NPC puts it on my map or do I stumble upon it (usually because I am running away from skull level mobs) do I go there. No beeline to Vault 81 to buy Overseers guardian. I am also doing settlements this way, my PC does not know about Abernathy farm or the Ghouls tarberry bog, I wait until I hear NPC talk about it if I have not stumbled on it. This requires avoiding Preston - you still get radiants/defense missions though I think they seem more natural than coming from Preston.
I am really enjoying my no crafting perks rules, but that still requires workshop junk thus Local Leader for caravans, though I am considering breaking the rule for settlement upgrades as I did not realize some are perk locked. Taking the crafting table perks makes it way to easy to get OP weapons/armor before the NPC do, there is much more natural progression without them. I am still running around in spiky buttressed raider gear, it is actually better than the low level combat armour I am starting to find. I also leave any power armour I find for settlers, because no crafting means not being able to upgrade them.
The combination of these things adds improv to your roleplay, no elaborate backstory and PERK plan, what happens to you is random. Better matches the reality that your PC cannot be who they was before the freezer, as that experience changed you. Does your guy not roll STR/AGI, does your gal not roll INT/CHA? Then the freezer damaged them from being the soldier/lawyer they was. By saving the PC at Vault 111 exit redo it even makes plot sense that your SPECIAL is defined after the freezer.
The problem with no Stimpaks is whenever you get wounded, not only are they immediately crippling leading to likely death because you can barely move - these wounds stay with you. Look at your body part stats they each have their own wounds bar. OK if you are doing permawound as a variant of permadeath, but maybe not OK if you did not realize that happens! I am finding on Survival mode explosives are very crippling if not deadly, so not sure no Stimpaks would work out well. The main advantage of Survival is the very slow healing, this does change your combat strategy a lot, especially when you meet poison bugs because you cannot heal fast enough! I do encourage survival though if you want a challenge, bullet sponge enemies is easily RP as you hitting them with non deadly flesh wounds or armor glances while their druggy/rad state allows them to shrug it off - after all D&D works the same way with OP HP on NPC. Normal is way to easy for mowing down mobs even with perk nerfs.