Cardiac cephalalgia: severe, non-exertional headache presenting as unstable 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 20^th 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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01508-7.

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.

Episodic Migraine and Older Adults

PURPOSE OF REVIEW

Migraine is and continues to be a significant medical issue in older adults. Migraine can have different characteristics in older adults and specific diagnostic and treatment considerations need to be applied when managing headache and migraine in this population, which is increasing in both size and diversity. Contrary to widely held beliefs, migraine may not improve in older women following menopause and can have new onset in older age. The purpose of this review is to give an update on the diagnosis and treatment of episodic migraine in older adults.

RECENT FINDINGS

As the population ages, migraine in older adults will become a more significant public health issue. Migraine in older adults can present with different clinical symptoms than in a younger population and is primarily a diagnosis of exclusion in older adults. Migraine treatment considerations for older adults should include comorbidities and medication interactions. Recent findings suggest there are medications that should be avoided when treating seniors with migraine. The purpose of this review is to give an update on the most important aspects regarding the diagnosis and treatment of headache and migraine in older adults. In addition, recommendations will be made concerning medications that need careful consideration when prescribing to seniors.

Clinical analysis of 30 cases of cardiac cephalalgia

OBJECTIVE

To investigate the clinical characteristics of cardiac cephalalgia and determine whether there is a more suitable alternative criterion.

METHOD

Patients with cardiac cephalalgia diagnosed and treated from May 2019 to April 2021 in the First Affiliated Hospital of Zhengzhou University (Zhengzhou, China) were prospectively and consecutively collected, their clinical manifestations were analyzed, and compared with the 2018 diagnostic criteria.

RESULTS

A total of 30 patients were collected, including 16 males and 14 females. The onset age ranged from 31 to 84 years old, with a mean of 64.6 ± 11.9 years. Headache was more common in unilateral or bilateral frontotemporal, and the nature of pain includes pulsating, dull, stuffy pain, throbbing and so on. 80.0% were moderate to severe, 70% lasted less than half an hour, 76.6% had chest pain, 70% had chest tightness, 63.3% had sweating, and 36.6% had nausea. After treatment with drugs or coronary angiogenesis, except for one death, headache was fully or partially relieved in 29 patients.

CONCLUSION

Cardiac cephalalgia is generally located in frontotemporal region, of moderate or severe intensity, with a pulsating or throbbing sensation, abating within 30 minutes, and has a good prognosis. Accompanying chest pain, chest tightness, and sweating should be included in the diagnostic criteria.

Headache as a Neurologic Manifestation of Systemic Disease

Purpose of Review

Recent Findings

Summary

Cardiac cephalalgia closely associated with acute myocardial infarction

Cardiac cephalalgia is an uncommon symptom occurring in coronary artery disease. It is difficult to identify cardiac cephalalgia and link it to coronary artery disease because these patients present with only a headache and no typical symptoms of angina, such as chest pain, radiating pain, or chest tightness. Currently, the diagnostic value of cardiac cephalalgia in acute myocardial infarction is still under debate. We here report a case of cardiac cephalalgia. An 83-year-old woman with a severe headache lasting 6 h was diagnosed with acute myocardial infarction. ST elevation and severe stenosis of the right coronary artery were observed. Passage of the guide wire and radiocontrast agent increased the intensity of the headache, which disappeared once the right coronary artery was opened. As of one month into follow-up, the headache had not recurred. These observations strongly indicate a close association between cardiac cephalalgia and acute myocardial infarction, and they could help diagnose acute myocardial infarction related to headaches.