Angina Presenting as Exertional Headache
Source: Lipton RB, et al. Cardiac cephalgia: A treatable form of exertional headache. Neurology 1997;49:813-816.
Lipton and colleagues present two interesting patients with cardiac ischemia presenting as exertional headache. Both males aged 57 and 67 promptly developed severe bilateral head pain rated 10 of 10 in response to exertion. The pain lasted from minutes to hours. One man suffered nausea but otherwise no vomiting, light, sound, or smell sensitivity to note. Neither had a known past history of heart disease or obvious coronary risk factors other than hypertension in the 67-year-old. In both men, headache and ECG changes evolved during an exercise stress-thallium test. Most striking, neither man apparently complained of chest discomfort, diaphoresis, or palpitations. Cardiac catheterization demonstrated triple vessel coronary disease in both men. Headache resolved after successful treatment involving CABG in one and angioplasty in the other.
COMMENTARY
The authors make several noteworthy points. In a patient with exertional headache, one should first rule out intracranial structural lesions. Thereafter, it is the temporal profile that helps distinguish this rare but perhaps under recognized entity. As the authors indicate, the headache closely associates in time with vigorous exercise; it subsides with rest and improves with antianginal treatment. By contrast, other kinds of headaches may actually get worse with nitrates. New headache onset after age 50 should always raise concern but, specifically, in a patient with coronary risk factors. Differentiation from migraine, which can also develop after exertion, is critical. Vasoconstricting drugs like sumatriptan would be contraindicated in patients with anginal equivalents. jr
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