While migraine is considered the most common headache disorder in the United States, it is always imperative to rule out dangerous causes for headache with your physician, before arriving at that diagnosis. Headache is a common symptom of a multitude of medical conditions, medications and procedures. This article focuses on headache as a symptom of heart disease.
Some warning signs or red flags that may prompt physicians to pursue a workup include a new headache in a person aged greater than 50, a headache which worsens with position, coughing, exercise or a bowel movement and associated symptoms such as fever and weight loss. See Table 1 for a list of warning signs developed by Dr. Dodick and colleagues.
| S – Systemic constitutional symptoms like fever, weight loss, background systemic diseases, malignancy, immunosuppression |
| N – Neurological deficits or abnormalities on examination |
| O – Onset, thunderclap headache (TCH), or sudden severe headache |
| O – Age of onset greater than 50 |
| P4 – Progressive headache, Precipitation by valsalva maneuvers, aggravation with change in Position, the presence of papilledema on exam. |
Heart disease is an important consideration in people with migraine. The connection between migraine (with or without aura) and cardiovascular diseases such as stroke and heart attack has been established and as a result, people presenting with headache should be evaluated for cardiac causes and people with cardiovascular disease should be asked about their headache history. When we treat patients with a history of heart attack or stroke for migraine, we tend to avoid certain medications such as triptans which are contraindicated. Less has been studied about headache as a symptom of a cardiac event even though migraine has been identified as a risk factor for myocardial infarction AKA heart attack.
Cardiac cephalalgia is a rare, migraine-like headache that coincides with a loss of blood flow to the heart which is relieved with nitroglycerin. The headache that occurs with cardiac cephalalgia can be migraine-like and may occur with or without chest pain. The headache is often worsened with exercise and is relieved with nitroglycerin. To confirm the diagnosis, your neurologist will enlist the help of a cardiologist who will likely obtain an electrocardiogram or a coronary angiography to confirm acute myocardial ischemia. Your neurologist may also order a magnetic resonance imaging (MRI) study of the brain and arteries of the brain and a lumbar puncture. If a blocked coronary artery is found, it can be medically and/or procedurally treated. As a result, the headaches should completely resolve. A prompt and accurate diagnosis is essential to reducing morbidity and mortality. If you have headaches and a history of cardiovascular risk factors such as diabetes and hypertension, consider talking with your doctor about this dangerous cause for headache.