Headache angina

Headache as the sole clinical manifestation of acute myocardial infarction: one case with cardiac cephalalgia and literature review

OBJECTIVE

Cardiac cephalalgia, once seen as a rare symptom of coronary artery disease, is now more recognized. It often comes with chest discomfort and autonomic dysfunction, worsened by physical activity. However, not all cases have chest symptoms or are activity induced. This report presents a case of cardiac cephalalgia and reviews 46 previous cases.

METHOD

We discuss a unique case where a patient had headache attacks without chest symptoms, autonomic dysfunction, or triggers. We reviewed English case reports of cardiac cephalalgia from 1982 to 2022 using PubMed (http://www.ncbi.nlm.nih.gov/pubmed).

RESULTS

A 69-year-old man presented with a sudden headache without triggers or typical symptoms. Coronary computed tomography angiography (CTA) showed diffuse stenosis in the left anterior descending and the first diagonal branch arteries. His headache improved after percutaneous coronary intervention. Cardiac cephalalgia is usually marked by severe headaches, autonomic signs, and often affects the occipital region. Electrocardiogram (ECG) might not always show abnormalities, and chest pain is not always present. In such cases, elevated cardiac enzymes can be crucial for diagnosis.

CONCLUSION

When a headache is the sole symptom of an acute coronary event, consider moderate to severe intensity, older age at onset, occipital localization, and autonomic signs. ECG, cardiac enzymes, and coronary CTA are valuable for accurate diagnosis and treatment.

Cardiac cephalalgia: a narrative review and ICHD-3 criteria evaluation

BACKGROUND

Cardiac cephalalgia is an unusual condition that occurs during an episode of myocardial ischemia. Information about cardiac cephalalgia is scarce and its characteristics and physiopathology remain unclear. Our aim is to provide a narrative review of clinical characteristics and physiopathology of cardiac cephalalgia and to evaluate the current diagnostic criteria.  METHODS: A search through PubMed was undertaken for studies on cardiac cephalalgia published until 20th September 2022. We summarized the literature and provide a comprehensive review of the headache characteristics and possible mechanisms. We also evaluated current International Classification of Headache Disorders third edition diagnostic criteria based on prior reported cases.  RESULTS: In total, 88 cases were found. Headache characteristics were variable. Occipital location and throbbing pain were the most frequently reported. Headache was accompanied in most cases by cardiac symptoms. Criterion B was fulfilled by 98% of cases, criterion C1 by 72%, and criteria C2a and C2b by 37 and 93.2%, respectively. Regarding headache features described in diagnostic criterion C3, 'moderate to severe intensity', 'accompanied by nausea', 'not accompanied by photophobia or phonophobia' and 'aggravated by exertion', were reported in 75, 31, 55 and 55% of cases, respectively.

CONCLUSION

Cardiac cephalalgia characteristics are variable and the headache features described in the diagnostic criterion C3 might not be adequate. Given that cardiac cephalalgia can be the manifestation of a life-threatening condition it is important to increase the knowledge about this entity.

Cardiac cephalalgia: a case series of four patients and updated literature review

Background

Cardiac damage is common in patients with acute brain injury; however, little is known regarding cardiac-induced neurological symptoms. In the International Classification of Headache, Third Edition (ICHD-III), cardiac cephalalgia is classified as a headache caused by impaired homeostasis.

Methods

This report presents four patients with acute myocardial infarction (AMI) who presented with headache that fulfilled the ICHD-III diagnostic criteria for cardiac cephalalgia. A systematic review of cardiac cephalalgia using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines is also presented.

Results

Case 1: A 69-year-old man with a history of percutaneous coronary intervention (PCI) developed sudden severe occipital pain, nausea, and cold sweating. Coronary angiography (CAG) revealed occlusion of the right coronary artery (RCA). Case 2: A 66-year-old woman complained of increasing occipitalgia and chest discomfort while riding a bicycle. CAG demonstrated 99% stenosis of the left anterior descending artery. Case 3: A 54-year-old man presented with faintness, cold sweating, and occipitalgia after eating lunch. CAG detected occlusion of the RCA. Case 4: A 72-year-old man went into shock after complaining of a sudden severe headache and nausea. Vasopressors were initiated and emergency CAG was performed, which detected three-vessel disease. In all four, electrocardiography (ECG) showed ST segment elevation or depression and echocardiography revealed a left ventricular wall motion abnormality. All patients underwent PCI, which resulted in headache resolution after successful coronary reperfusion. A total of 59 cases of cardiac cephalalgia were reviewed, including the four reported here. Although the typical manifestation of cardiac cephalalgia is migraine-like pain on exertion, it may present with thunderclap headache without a trigger or chest symptoms, mimicking subarachnoid hemorrhage. ECG may not always show an abnormality. Headaches resolve after successful coronary reperfusion.

Conclusions

Cardiac cephalalgia resulting from AMI can present with or without chest discomfort and even mimic the classic thunderclap headache associated with SAH. It should be recognized as a neurological emergency and treated without delay.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-022-00436-2.

Cardio-Pulmonary Dysfunction Evaluation in Patients with Persistent Post-COVID-19 Headache

Background (1): Headache is a prevalent symptom experienced during ongoing SARS-CoV-2 infection, but also weeks after recovery. Whether cardio-pulmonary dysfunction contributes causally to headache persistence is unknown. Methods (2): We conducted a case-control analysis nested in a prospective cohort study. Individuals were recruited from August 2020 to December 2020. Patients were grouped according to the presence or absence of long-COVID headache for three months after COVID-19 resolution. We compared demographic data, clinical variables, cardio-pulmonary laboratory biomarkers, quality of life, and cardio-pulmonary function between groups. Results (3): A cohort of 70 COVID-19 patients was evaluated. Patients with headaches (n = 10; 14.3%) were more frequently female (100% vs. 58.4%; p = 0.011) and younger (46.9 ± 8.45 vs. 56.13 ± 12 years; p = 0.023). No between-group differences in laboratory analysis, resting echocardiography, cardio-pulmonary exercise test, or pulmonary function tests were observed. Conclusion (4): In this exploratory study, no significant differences in cardio-pulmonary dysfunction were observed between patients with and without long-COVID headache during mid-term follow-up.

Cardiac cephalgia: a diagnostic headache

A 73-year-old man presented with a 6-month history of exertional headaches. Exercise tolerance test demonstrated progressive ischaemic changes concomitant with worsening headache. Cardiac cephalgia was diagnosed and his symptoms resolved after coronary artery bypass surgery. Cardiac cephalgia may occasionally present as exertional headache without chest symptoms.

Primary cough headache, primary exertional headache, and primary headache associated with sexual activity

Activity-related headaches can be brought on by Valsalva maneuvers ("cough headache"), prolonged exercise ("exertional headache"), and sexual excitation ("orgasmic headache"). These headaches account for 1-2% of the consultations due to headache in a general neurological department. These entities are a challenging diagnostic problem as they can be primary or secondary and as their etiologies differ depending on the headache type. About 50% of patients with cough headache will show no demonstrable etiology, while the other half will be secondary to structural lesions, mostly a Chiari type I malformation at the foramen magnum level. As compared to the primary variety, secondary cough headache begins earlier (average 40 versus 60 years), is located posteriorly, lasts longer (years versus months), is associated with posterior fossa symptoms/signs, and does not respond to indomethacin. Patients with secondary cough headache show difficulties in cerebrospinal fluid circulation in the foramen magnum region in dynamic magnetic resonance imaging studies and preoperative plateau waves, which disappear after posterior fossa reconstruction. Headaches provoked by physical exercise and sexual headache have many points in common. In contrast to cough headache, secondary cases are rare, and sentinel subarachnoid bleeding is the most frequent etiology. The mean age at onset for primary headaches provoked by physical exercise and sexual activity is similar (40 years); they share clinical characteristics (bilateral, pulsating) and respond to beta-blockers. In conclusion, provoked headaches account for a low proportion of headache consultations. Cough headache is a different condition when compared to headache due to physical exercise and sexual activity, which are clinical variants of the same entity.

Other primary headaches

This article reviews "other primary headaches," a classification of the International Headache Society that includes primary stabbing headaches, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, and new daily persistent headache. Clinicians should be aware that these headaches may be symptomatic to structural lesions and therefore usually require careful neuroimaging evaluation.

Cardiac cephalgia

The purpose of this review was to provide a critical evaluation of medical literature on so-called “cardiac cephalgia” or “cardiac cephalalgia”. The 2004 International Classification of Headache Disorders codes cardiac cephalgia to 10.6 in the group of secondary headaches attributed to disorder of homoeostasis. This headache is hardly recognizable and is associated to an ischaemic cardiovascular event, of which it may be the only manifestation in 27% of cases. It usually occurs after exertion. Sometimes routine examinations, cardiac enzymes, ECG and even exercise stress test prove negative. In such cases, only a coronary angiogram can provide sufficient evidence for diagnosis. Cardiac cephalgia manifests itself without a specific pattern of clinical features: indeed, in this headache subtype there is a high variability of clinical manifestations between different patients and also within the same patient. It “mimics” sometimes a form of migraine either accompanied or not by autonomic symptoms, sometimes a form of tension-type headache; on other occasions, it exhibits characteristics that can hardly be interpreted as typical of primary headache. Pain location is highly variable. When the headache occurs as the only manifestation of an acute coronary event, the clues for suspicion are a) older age at onset, b) no past medical history of headache, c) presence of risk factors for vascular disorders and d) onset of headache under stress. Knowledge of cardiac cephalgia is scarce, due to its rare clinical occurrence and to the scant importance given to headache as a symptom concomitantly with an ischaemic cardiac event.

Cardiac cephalalgia: case reports and review

Diagnosis of myocardial infarction or acute coronary syndrome is difficult, especially in atypical presentation at an emergency department, and sometimes results in serious legal issues. Symptoms of atypical presentation include shortness of breath, dyspnoea on exertion, toothache, abdominal pain, back pain and throat pain. As of now, reports of a headache, especially exertional headache, as the only presentation of acute cardiac ischaemia are rare and only have case reports. We present two patients with a cardiac source of headache and analyse 32 patients with similar situations from MEDLINE search from 1966 to the present. Cardiac cephalalgia is benign in general, but potential risks for death should be considered. If the patient has increased risk of atherosclerosis with exertional headache, anginal headache should be highly suspected and further work-up should be undertaken.

Exertional headache and coronary ischemia despite normal electrocardiographic stress testing

Exertional headaches may under certain conditions reflect coronary ischemia. We report the case of a patient seen in a neurology referral practice whose exertional headaches, even in the face of two normal electrocardiographic stress tests and in the absence of underlying chest pain were the sole symptoms of coronary ischemia as detected by Tc-99m Sestamibi testing SPECT stress testing. Stent placement resulted in complete resolution of headaches. Exertional headache in the absence of chest pain may reflect underlying symptomatic coronary artery disease (CAD) even when conventional electrocardiographic stress testing does not indicate ischemia.

Acute non-ST-elevation myocardial infarction presented as occipital headache with impaired level of consciousness--a case report

Headache represents a rare manifestation of myocardial ischemic pain. It is believed that this clinical symptom results from convergence of heart autonomic fibers with somatic inputs originating from the head. The authors describe for the first time the case of a 73-year-old woman who experienced an acute non-ST-elevation myocardial infarction that manifested solely with intense occipital headache associated with vomiting and impaired level of consciousness. This unusual case highlights that the exclusion of an intracranial event in patients presenting with a severe headache and ischemic-like electrocardiographic abnormalities should raise the possibility of an acute coronary event, especially in elderly individuals with cardiovascular risk factors. Furthermore, the occurrence of episodic short-lasting headaches during exertion should direct diagnostic work-up toward ischemic heart disease.