Headache as the sole presentation of acute myocardial infarction in two elderly patients

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.

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.

Cardiac cephalalgia: one case with cortical hypoperfusion in headaches and literature review

BACKGROUND

Cardiac cephalalgia (CC) is a rare disease occurring during an episode of myocardial ischemia and relieved by nitroglycerine. Though more than 30 cases of CC have been reported since 1997, the mechanism is yet obscure. Herein, a case of CC is presented and discussed in relevance with previous literature to propose a novel hypothesis about the mechanism of CC.

METHOD

A CC patient with cortical hypoperfusion during headache attacks was presented, which has never been reported. All published cases of CC via PubMed ( http://www.ncbi.nlm.nih.gov/pubmed ) in English literature, between 1997 and 2016, were reviewed.

RESULTS

A patient suffering from CC presented a cerebral hypoperfusion during a headache attack. This phenomenon had not been observed since CC was introduced in 1997. The literature review summarized the clinical presentations, neuroimaging features, ECG, and coronary angiography features of 35 CC patients.

CONCLUSION

Based on the phenomenon of hypoperfusion in the event of a headache, the vessel constriction hypothesis was proposed including two potential physiological mechanisms underlying the pathophysiology of CC.

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.

Heart Attack Causes Head-Ache - Cardiac Cephalalgia

Chest pain is the typical symptom of myocardial infarction (MI), and there are many atypical manifestations such as stomachache or dyspnea. Headache is a rare presentation of MI, which has specifically been termed "cardiac cephalalgia" or "cardiac cephalgia". In this article, we have reported a case of sudden onset headache and neck pain, of whom MI was confirmed by electrocardiography, cardiac markers, and coronary angiogram. The patient's headache subsided dramatically after coronary angioplasty, and it had not recurred in the following one year. Additionally, diagnostic clues and possible mechanisms of cardiac cephalalgia are discussed as well.

KEY WORDS

Headache • Cardiac cephalgia • Cardiac cephalalgia • Myocardial infarction.

A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based?

Background

There are many potential causes of sudden and severe headache (thunderclap headache), the most important of which is aneurysmal subarachnoid haemorrhage. Published academic reviews report a wide range of causes. We sought to create a definitive list of causes, other than aneurysmal subarachnoid haemorrhage, using a systematic review.

Methods

Systematic Review of EMBASE and MEDLINE databases using pre-defined search criteria up to September 2009. We extracted data from any original research paper or case report describing a case of someone presenting with a sudden and severe headache, and summarized the published causes.

Results

Our search identified over 21,000 titles, of which 1224 articles were scrutinized in full. 213 articles described 2345 people with sudden and severe headache, and we identified 6 English language academic review articles. A total of 119 causes were identified, of which 46 (38%) were not mentioned in published academic review articles. Using capture-recapture analysis, we estimate that our search was 98% complete. There is only one population-based estimate of the incidence of sudden and severe headache at 43 cases per 100,000. In cohort studies, the most common causes identified were primary headaches or headaches of uncertain cause. Vasoconstriction syndromes are commonly mentioned in case reports or case series. The most common cause not mentioned in academic reviews was pneumocephalus. 70 non-English language articles were identified but these did not contain additional causes.

Conclusions

There are over 100 different published causes of sudden and severe headache, other than aneurysmal subarachnoid haemorrhage. We have now made a definitive list of causes for future reference which we intend to maintain. There is a need for an up to date population based description of cause of sudden and severe headache as the modern epidemiology of thunderclap headache may require updating in the light of research on cerebral vasoconstriction syndromes.

Secondary headaches

PURPOSE OF REVIEW

This article identifies the pertinent historical issues that lead to the identification of those headaches needing additional testing to exclude a serious underlying cause.

RECENT FINDINGS

Recurrences of giant cell arteritis, even after presumed successful treatment, are common. Postural orthostatic tachycardia syndrome is an often unrecognized cause of headache.

SUMMARY

Patients with a primary headache disorder are more susceptible to the development of headache when a secondary cause occurs. Their headaches may be phenotypically similar to their primary headache disorder. Therefore, a secondary cause should be considered in patients with preexisting headache disorders who develop a significant increase in the number and severity of those attacks.

Acute myocardial infarction manifested with headache

We report a very rare case of a patient who presented with headache as the sole symptom of an acute myocardial infarction (AMI). The patient underwent primary percutaneous coronary angioplasty followed by drug-eluting stent implantation and the headache was immediately relieved. The pathophysiologic explanation of the occurrence of headache as a sole manifestation of an AMI is discussed.

Should acute myocardial infarction be considered in the differential diagnosis of headache?

AIM

Headache as the only presenting symptom of acute myocardial infarction (MI) is an extremely uncommon phenomenon. The aim of this report is to describe a 61 year-old female patient with exertional headaches being the solely presentation of acute MI.

METHODS

As there were no complaints of chest pains or any other symptoms suggestive for MI, she underwent extensive neurological work-up. The correct diagnosis, however, was established only after a detailed description of the localization and radiation of her pains was obtained.

CONCLUSION

The importance of a thoroughly obtained anamnesis for the early recognition of cases with MI presenting with headaches, as well as the difference of opinion concerning the correct diagnosis which may occur between the internist and the cardiologist, are discussed.

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.

Headache angina

The initial recognition of acute myocardial infarction at the time of the emergency department (ED) visit may be difficult in the absence of typical presentations such as chest pain, diaphoresis, and radiation tenderness. Headache angina, although reported in several instances in the past with variable patient outcomes, is still an uncommon phenomenon in patients with acute myocardial infarction. We report a patient with inferior myocardial infarction who presented to the ED with a complaint of severe headache and subsequent cardiogenic shock secondary to ventricular fibrillation.

[Headache and facial pain in the elderly]

Whilst headache disorders belong to the most common health problems of the younger population, the occurrence diminishes with advancing age. However, in individual cases headaches may be especially severe in old age significantly reducing the quality of life. Typical causes of headache in the elderly are giant cell arteritis (arteritis temporalis), cranial neuralgia and hypnic headache. The incidence of intracranial mass lesions also increases with age. In addition to these secondary forms of headache, the typical primary headache disorders migraine, tension headache and cluster headache may also persist in the elderly. In drug treatment of headaches in the elderly, an impairment of renal and/or hepatic function has to be taken in account, as should be the potential multimorbidity of elderly patients.

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.

Clinical Diagnoses and Autopsy Findings: A Retrospective Analysis of 252 Cases in Greece

Context.—Despite medical and technologic advances, clinicians may misdiagnose a patient's situation and the cause of death. Autopsy may be valuable in uncovering the most frequent diagnostic pitfalls and helping clinicians to learn and to develop the medical art and science.

Objective.—To compare the clinical diagnoses with postmortem findings and evaluate the frequency of diagnostic errors assessed by autopsies.

Design.—Retrospective analysis of the protocols of 252 consecutive cases of adult patients autopsied in the Department of Forensic Medicine and Toxicology of Athens Medical School during the period 1999–2003. The outcome measures included concordance between diagnosis before death and at autopsy, sex, age, and length of hospitalization of the patient.

Results.—In 73 cases (29%), the autopsy findings confirmed the clinical diagnosis and the cause of death suggested by the clinicians. In 45 cases (19%), the clinical diagnosis and the cause of death suggested by the clinicians were discordant with the autopsy findings. In 105 cases (42%), the autopsy requests did not include any suggestion about the cause of the patient's death. In 7 cases (3%), several diagnoses were suggested by the clinicians, and in 16 cases (6%), the comparison between clinical and postmortem diagnosis was not possible. The most frequently misdiagnosed diseases were coronary disease and pulmonary embolism.

Conclusions.—It is concluded from this study that autopsies may reveal unexpected findings that are of critical importance and that a continued emphasis on autopsy evaluation is necessary to improve the quality of patient care.

Reducing diagnostic errors in medicine: what's the goal?

This review considers the feasibility of reducing or eliminating the three major categories of diagnostic errors in medicine: "No-fault errors" occur when the disease is silent, presents atypically, or mimics something more common. These errors will inevitably decline as medical science advances, new syndromes are identified, and diseases can be detected more accurately or at earlier stages. These errors can never be eradicated, unfortunately, because new diseases emerge, tests are never perfect, patients are sometimes noncompliant, and physicians will inevitably, at times, choose the most likely diagnosis over the correct one, illustrating the concept of necessary fallibility and the probabilistic nature of choosing a diagnosis. "System errors" play a role when diagnosis is delayed or missed because of latent imperfections in the health care system. These errors can be reduced by system improvements, but can never be eliminated because these improvements lag behind and degrade over time, and each new fix creates the opportunity for novel errors. Tradeoffs also guarantee system errors will persist, when resources are just shifted. "Cognitive errors" reflect misdiagnosis from faulty data collection or interpretation, flawed reasoning, or incomplete knowledge. The limitations of human processing and the inherent biases in using heuristics guarantee that these errors will persist. Opportunities exist, however, for improving the cognitive aspect of diagnosis by adopting system-level changes (e.g., second opinions, decision-support systems, enhanced access to specialists) and by training designed to improve cognition or cognitive awareness. Diagnostic error can be substantially reduced, but never eradicated.