Cardiac cephalalgia is a symptom of the most common type of heart disease – ischaemic heart disease – due to narrowing of the main arteries supplying heart muscle (coronary stenosis).
This is a very rare syndrome, as when I have talked to cardiologists they have sometimes been sceptical of its existence.
The cardiologists argue that they have seen hundreds of people with heart attacks, angina or rhythm disturbances yet cannot recall anyone with severe headache.
At the time of a heart attack or angina episode about 6% of people will report headache at the time of the onset of the heart problem as well as the dominant symptom of chest or arm pain (according to one survey of about 150 people).
However, there are some very convincing cases of people with narrowed coronary arteries who experienced headache during their heart attack or angina episode.
While their arteries were being treated at angioplasty headache appeared when the angioplasty balloon was inflated.
These people reported resolution of headache symptoms once the arteries were treated.
According to the largest review of 34 cases, about half of cardiac cephalalgia cases will be having a heart attack, about 40% will be having angina and about 10% of cases are experiencing a heart rhythm disturbance.
There is a list of all 41 published papers on cardiac headaches at the foot of the page.
What types of heart disease cause headaches?
These heart conditions are serious as up to 12% of people died of the heart disease that had caused their headache condition.
The headache of heart disease is usually dull, one sided, and experienced in the face, eye or forehead. It can even be felt in the back of the head (about 20% in one series were occipital headache).
There has been a recent case of Thunderclap Headache caused by an acute heart attack.
Like angina, heart-disease headaches are brought on by exercising, including the exertion associated with sexual activity.
The most comprehensive review of cardiac cephalalgia by Drs Wie and Wang 2008 reviewed 34 cases.
It is interesting to note that 11/34 cases had eye pain as a manifestation of their cardiac condition. This may be a clinical pointer – consider heart disease in exertional unilateral eye pain. Cardiac pain can also present as isolated ear pain.
Headache has been noted in up to 6% of angina sufferers (out of a series of nearly 200 people), yet none had pure headache.
This means that heart disease should not be the first consideration in diagnosis of headache. However, as fatal cases are recorded, the diagnosis is something anyone treating severe headaches should know.
An older person with cardiovascular risk factors who presents with thunderclap headache or exercise headache would be the sort of person I’d have in mind.
My own experience of cardiac cephalalgia was an older man presenting to hospital with occipital headache and breathlessness, who subsequently was diagnosed as non-ST elevation MI and congestive cardiac failure. Another gentleman, in his 70s, developed headaches on exercise which were related to angina.
What diagnostic tests should I perform?
If you think of this diagnosis, then – usually a treadmill test is necessary to try and establish a diagnosis. Descriptions of further cardiac investigations are beyond my area of expertise.
Any exercise induced headache should also have brain imaging, usually a CT Brain is sufficient.
However, if the headache was thunderclap, then a Lumbar Puncture should be performed.
Why is heart pain felt in the head?
The explanation usually given for heart disease being sensed in the head is the phenomenon of “neural convergence”.
The vagus nerve is the main nerve from the heart which transmits angina pain to the brain. In the upper part of the spinal cord, fibres from the vagus nerve converge (or mix) with fibres from the trigeminal nerve.
The trigeminal nerve is that main sensory nerve of the head and face. It is through activation of the trigeminal nerve from these connecting vagus nerve fibres that heart attack pain or angina pain becomes a heart disease headache or cardiac cephalalgia.
1. Lefkowitz D, Biller J. Bregmatic headache as a manifestation of myocardial ischemia. Arch Neurol. 1982;39(2):130.2. Lefkowitz D, Biller J. Mechanisms of headache with angina. Arch Neurol. 1983;40(2):127.
3. Blacky RA, Rittelmeyer JT, Wallace MR. Headache angina. Am J Cardiol. 1987;60(8):730.
4. Takayanagi K, Fujito T, Morooka S, Takabatake Y, Nakamura Y. Headache angina with fatal outcome. Jpn Heart J. 1990;31(4):503-7.
5. Nagori SB. Global headache in angina pectoris. J Assoc Physicians India. 1992;40(3):212.
6. Bowen J, Oppenheim G. Headache as a presentation of angina: reproduction of symptoms during angioplasty. Headache. 1993;33(5):238-9.
7. Ishida A, Sunagawa O, Touma T, Shinzato Y, Kawazoe N, Fukiyama K. Headache as a manifestation of myocardial infarction. Jpn Heart J. 1996;37(2):261-3.
8. Grace A, Horgan J, Breathnach K, Staunton H. Anginal headache and its basis. Cephalalgia. 1997;17(3):195-6.
9. Lipton RB, Lowenkopf T, Bajwa ZH, Leckie RS, Ribeiro S, Newman LC, et al. Cardiac cephalgia: a treatable form of exertional headache. Neurology. 1997;49(3):813-6.
10. Tomcsanyi J, Wettstein A, Somloi M, Engelthaler G, Karlocai K. [Headache as a symptom of angina]. Orv Hetil. 1997;138(46):2939-40.
11. Gilbert GJ. Cardiac cephalgia. Neurology. 1998;50(3):836.
12. Lance JW, Lambros J. Unilateral exertional headache as a symptom of cardiac ischemia. Headache. 1998;38(4):315-6.
13. Lanza GA, Sciahbasi A, Sestito A, Maseri A. Angina pectoris: a headache. Lancet. 2000;356(9234):998.
14. Amendo MT, Brown BA, Kossow LB, Weinberg FM. Headache as the sole presentation of acute myocardial infarction in two elderly patients. Am J Geriatr Cardiol. 2001;10(2):100-1.
15. Auer J, Berent R, Lassnig E, Eber B. Headache as a manifestation of fatal myocardial infarction. Neurol Sci. 2001;22(5):395-7.
16. Rambihar VS. Headache angina. Lancet. 2001;357(9249):72.
17. Famularo G, De Simone C. Headache and acute coronary syndromes. Headache. 2002;42(4):320-1; author reply 1-2.
18. Famularo G, Polchi S, Tarroni P. Headache as a presenting symptom of acute myocardial infarction. Headache. 2002;42(10):1025-8.
19. Gutierrez-Morlote J, Pascual J. Cardiac cephalgia is not necessarily an exertional headache: case report. Cephalalgia. 2002;22(9):765-6.
20. Martinez HR, Rangel-Guerra RA, Cantu-Martinez L, Garza-Gomez J, Gonzalez HC. Cardiac headache: hemicranial cephalalgia as the sole manifestation of coronary ischemia. Headache. 2002;42(10):1029-32.
21. Petersen JA, Nielsen FE. [Headache: a rare manifestation of angina pectoris]. Ugeskr Laeger. 2002;164(19):2515-6.
22. Chen SP, Fuh JL, Yu WC, Wang SJ. Cardiac cephalalgia. Case report and review of the literature with new ICHD-II criteria revisited. Eur Neurol. 2004;51(4):221-6.
23. Garg A, Bohra P, Gupta MK. Angina pectoris presenting as headache. Indian Heart J. 2004;56(6):685-6.
24. Sathirapanya P. Anginal cephalgia: a serious form of exertional headache. Cephalalgia. 2004;24(3):231-4.
25. Gutierrez Morlote J, Fernandez Garcia JM, Timiraos Fernandez JJ, Llano Cardenal M, Rodriguez Rodriguez E, Pascual Gomez J. [Cardiac cephalgia: an underdiagnosed condition? ]. Rev Esp Cardiol. 2005;58(12):1476-8.
26. Korantzopoulos P, Karanikis P, Pappa E, Dimitroula V, Kountouris E, Siogas K. Acute non-ST-elevation myocardial infarction presented as occipital headache with impaired level of consciousness–a case report. Angiology. 2005;56(5):627-30.
27. Greiner F, Rothrock J. Thunderclap headache, cardiopulmonary arrest, and myocardial infarction. Headache. 2006;46(3):512.
28. Broner S, Lay C, Newman L, Swerdlow M. Thunderclap headache as the presenting symptom of myocardial infarction. Headache. 2007;47(5):724-5.
29. Hakeem A, Marks AD, Bhatti S, Chang SM. When the worst headache becomes the worst heartache! Stroke. 2007;38(12):3292-5.
30. Seow VK, Chong CF, Wang TL, Ong JR. Severe explosive headache: a sole presentation of acute myocardial infarction in a young man. Am J Emerg Med. 2007;25(2):250-1.
31. Wang WW, Lin CS. Headache angina. Am J Emerg Med. 2008;26(3):387.e1-2.
32. Wei JH, Wang HF. Cardiac cephalalgia: case reports and review. Cephalalgia. 2008;28(8):892-6.
33. Bini A, Evangelista A, Castellini P, Lambru G, Ferrante T, Manzoni GC, et al. Cardiac cephalgia. J Headache Pain. 2009;10(1):3-9.
34. Saikia PK, Chakrabarti D. Headache as the sole presenting symptom of acute myocardial infarction. J Assoc Physicians India. 2009;57:83-4.
35. Sendovski U, Rabkin Y, Goldshlak L, Rothmann MG. Should acute myocardial infarction be considered in the differential diagnosis of headache? Eur J Emerg Med. 2009;16(1):1-3.
36. Cheng PY, Sy HN, Chen WL, Chen YY. Cardiac cephalalgia presented with a thunderclap headache and an isolated exertional headache: report of 2 cases. Acta Neurol Taiwan. 2010;19(1):57-61.
37. Yang Y, Jeong D, Jin DG, Jang IM, Jang Y, Na HR, et al. A case of cardiac cephalalgia showing reversible coronary vasospasm on coronary angiogram. Journal of clinical neurology (Seoul, Korea). 2010;6(2):99-101.
38. Costopoulos C. Acute coronary syndromes can be a headache. Emerg Med J. 2011;28(1):71-3.
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