Cardiac Headaches: Beware of the Rare

abstract & commentary

Source: Lanza GA, et al. Angina pectoris: A headache. Lancet 2000;356:998.

Lanza and colleagues report the case of a 68-year-old man in whom myocardial ischemia presented as headache. The patient had a three-year history of brief occipital headaches occurring at rest.

One week before admission to the hospital, his headaches increased in frequency. At that time, brain MRI, chest radiographs, electrocardiogram (ECG), and routine laboratory tests all were normal. Cardiovascular risk factors included smoking and hypercholesterolemia.

On the day of admission, he reported a constant headache with pain in both shoulders. ECG was unchanged but serum levels of both CK-MB and cardiac Troponin I were elevated. Headache subsided after nitrates, ß-blockers, and aspirin were administered.

Two days later, during an exercise test, he reported typical headache symptoms concomitant with ECG abnormalities. Symptoms again were relieved by sublingual nitrates. He underwent coronary angiography and coronary artery bypass grafting of his left anterior descending and circumflex coronary arteries following which he remained headache free during three years of follow-up.

Commentary

In this patient, the response of his headaches to nitrates, which more frequently cause headache rather than relieving it, was a clue to the myocardial cause of his occipital symptoms. Cardiac pain typically can be referred to areas besides the chest such as the neck, jaw, arms, and epigastrium (Meller ST, Gebhart GF. Neuroscience 1992;488:501-524). Headache as a symptom of myocardial ischemia is rare but has been reported previously (Lefkowitz D, Biller J. Arch Neurol 1982;39:130; Lipton RB, et al. Neurology 1997;49:813-816). The site of "cardiac headache" is not specifically occipital and can also be frontal, parietal, temporal, or vertex in location.

Physicians should consider a cardiac origin of headache when it is episodic, lasts only a few minutes, or is exercise-induced and relieved by rest, particularly in patients with cardiovascular risk factors. —John J. Caronna