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DOI 10.1007/s11916-015-0481-4
Cardiac Cephalgia
Yasar Torres-Yaghi & Justin Salerian & Carrie Dougherty
Abstract Cardiac cephalgia is a type of secondary headache disorder, usually initiated by exertion that is related to
myocardial ischemia. Primary exertional headaches such as
sex-, cough-, or exercise-induced headaches are typically benign. Cardiac cephalgia, on the other hand, can have lifethreatening complications. Due to overlapping features and
similarities in presentation, cardiac cephalgia can be
misdiagnosed as a primary headache disorder such as migraine. However, the management of these conditions is
unique, and treatment of cardiac cephalgia with vasoconstrictors intended for migraine can potentially worsen myocardial
ischemia. Thus, it is important to make the correct diagnosis
by evaluating cardiac function with an electrocardiogram and/
or stress testing. In this review, we examine reported cases of
cardiac cephalgia from the past 5 years to highlight the importance of this condition in the differential diagnosis of a headache in a patient with a history of cardiovascular risk factors,
as well as to discuss the appropriate approach to diagnosis and
the proposed pathogenic mechanisms of this condition.
Keywords Cardiac cephalgia . Cardiac cephalalgia .
Migraine . Migrainous thoracalgia
Introduction
Clinical Features
Cardiac cephalgia is classified as a secondary headache syndrome. According to the International Classification of Headache Disorders (ICDH-II) diagnostic criteria of 2004, it is
characterized as a headache that is aggravated by exertion,
accompanied by nausea, and develops in the setting of acute
myocardial ischemia [3]. It also, by definition, resolves without recurrence after effective medical or surgical therapy for
the myocardial ischemia. Diagnostic tools are used to evaluate
myocardial ischemia when cardiac cephalgia is suspected. A
neurologic workup is routinely performed for the headache
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Diagnosis
Neurologic workup for refractory or unusual headache presentation often includes brain imaging and/or lumbar puncture.
When such studies are negative, or in cases where cardiac
origin of the headache is suspected secondary to presence of
cardiac risk factors or concurrent cardiac symptoms such as
chest pain, a cardiac workup is also warranted.
Laboratory studies, EKG, echocardiogram, stress testing,
and coronary angiography are the most frequently used tools
to evaluate myocardial function. Youngsoon et al. report a
case of a patient with a severe headache whose workup revealed normal results for routine laboratory tests and neurologic workup, including computed tomography of the head,
magnetic resonance imaging of brain and cerebral arteries,
electroencephalogram, and cerebral spinal fluid studies. The
presence of chest pain in this case prompted cardiac testing,
and after an EKG was found to be normal, a stress test revealed ST segment depression and the diagnosis of cardiac
cephalgia was made [8].
Although cardiac stress testing is a valuable tool that often
leads to the diagnosis of myocardial ischemia [8, 15], in the
setting of an acute coronary syndrome, there is often not
enough time to perform stress testing. EKG testing is rapid
and useful but can result in a normal initial reading despite the
presence of myocardial ischemia that is later revealed upon
further testing [7, 8, 15, 19].
Coronary angiography is important for the diagnosis of
an acute coronary event and is often performed as both a
diagnostic and therapeutic measure if EKG or stress testing demonstrates evidence of myocardial ischemia. A case
of ongoing intermittent headaches presented with a severe
headache and chest pain was found to be secondary to
variant angina after an angiogram with acetylcholine
provocation revealed coronary vasospasm. During the angiogram, the vasospasm directly induced both chest pain
and headache. Symptoms resolved completely after administration of intra-arterial nitroglycerine and subsequent
vasodilation [8].
No
No
Severe
Severe
Frontal and
bitemporal
Bi-frontal
Occipital
Frontal, radiating Severe
to jaw,
neck, back
Yiannis
42/M 4 h
et al. [7].
Yang
44/F 10 month prior
et al. [8].
Costopoulos 55/M 6 weeks
et al. [9].
Sendovski 61/F 3 weeks
et al. [10].
Yes
Variable
No
Exertion L
Positive
Stress test
Normal
ST depression
laterally,
ST elevation
Left anterior
descending
artery occlusion
Triple vessel
disease
Left anterior
descending
artery stenosis
Left anterior
descending
artery stenosis
Coronary
angiogram
Outcome Discharge
status
Alive
Resolved Alive
Resolved Alive
Resolved Alive
Percutaneous
Resolved Alive
coronary
angioplasty,
stenting
Percutaneous
Resolved Alive
coronary
angioplasty,
stenting
Coronary artery *
Alive
bypass graft
Therapy
Percutaneous
coronary
angioplasty,
stenting
ST depression Coronary
Intra-arterial
artery spasm
nitroglycerine
*
Triple vessel disease Coronary artery
bypass graft
*
Triple vessel disease Coronary artery
bypass graft
ST depression
*
anteriorly,
and ST elevation
posteriorly
Initially normal,
*
repeat Q waves,
and ST elevation
Q wave
Exertion None
Exertion None
EKG
findings
Risk factors for coronary artery disease are listed and include H hypertension, L hyperlipidemia, D diabetes, and S smoking
This table lists the clinical features seen in cases of headache and cardiac ischemia from articles published since 2009. Diagnostic tests, therapeutic interventions, and outcomes are described for each case.
An asterisk (*) indicates that the data was not included in the publication
Severe
Severe
Occipital
Dimitros
86/M New onset
et al. [6].
Risk
Factors
Exertion *
Trigger
Right sided, *
pleuritic
Severe
No
Intensity Chest
pain
Site
Severe
Age/ HA onset,
sex history
Mathew
47/M HAs 7 years,
Occipital
et al. [4].
diag. migraine
Reference
Table 1
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Differential Diagnosis
The differential diagnosis of cardiac cephalgia remains broad.
It includes the primary headache syndromes such as migraine
and tension headache, as well as other secondary headache
syndromes such as exertional headache.
Factors that aid in diagnosis include older age, concurrent
medical conditions, presence of cardiac risk factors, occurrence of chest pain in the patient, and the absence of typical
features associated with other headache syndromes (such as
migraine aura). As described above, however, cardiac
cephalgia can occur without these risk factors, and diagnostic
studies to evaluate cardiac function are helpful in diagnosis.
Clinically, it is a difficult task to distinguish between cardiac
cephalgia and migraine specifically. Often, the diagnosis of cardiac cephalgia is missed, as the only definitive measure of diagnosing this condition is response to treatment of cardiac ischemia. Mathew et al. describe a patient who carried the diagnosis
of migraine for several years before experiencing an acute myocardial infarction. The patient experienced complete resolution
of his headaches after coronary angioplasty, which revealed that
the etiology of his headaches was cardiac cephalgia.
It is also important to remember that since both primary
headache syndromes and coronary artery disease are common,
Fig. 1 Pathways of referred pain
in coronary ischemia: This figure
illustrates various somatic
afferents that have potential
convergence with visceral
afferents in the spinal cord [5].
Reprinted with permission.
Elgharably Y, Iliescu C, Sdringola
S, Yusuf S. Headache: A
Symptom of Acute Myocardial
Infarction. European Journal of
Cardiovascular Medicine. 2012;
11 (111): 170174
Pathophysiology
Although the pathogenesis behind cardiac cephalgia remains
unknown, there are three proposed mechanisms for cephalgia
in the setting of heart disease. The first possible etiology
Conclusions
In addition to clinical reasoning, various diagnostic tools are
used in the diagnosis of cardiac cephalgia. Given the heterogeneity of presentation, diagnosis is difficult. Diagnostic tests
employed by neurologists may fail to elucidate positive findings. Neurologists, widely responsible for the workup and
evaluation of patients with headaches, may need to include
diagnostic studies for cardiac conditions in their armamentarium for headache disorders.
Compliance with Ethics Guidelines
Conflict of Interest Dr. Yasar Torres-Yaghi, Dr. Justin Salerian, and Dr.
Carrie Dougherty each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
Of major importance
1.
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2.