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Headache Acute Coronary Syndromes
Giuseppe Famularo, MD, PhD Rome, Italy
Posted July 2002
"Letters to the Editor", Headache 2002; 42:320

The study by Morgenstern and colleagues seems to support the view that patients who present to the emergency department with a chief complaint of acute headache suffer in most cases from a benign disorder. Most of their patients were young women whose symptoms subsided following administration of antiemetics or ketorolac. Headache was caused by a subarachnoid hemorrhage in only 3% of the cases analyzed in this report.

The authors chose not to emphasize the possibility that head pain could be the primary symptom of vascular disorders other than subarachnoid hemorrhage or stroke. In particular, no information is provided as to whether a workup routinely was performed to rule out an acute coronary syndrome in their sample of patients. Several studies have reported that headache, rather than the typical chest tightness, can be the only complaint described by patients with stable or unstable angina or even patients with acute myocardial infarction. We have had similar experience (manuscript in preparation).

Correct identification of headache as an equivalent of angina pectoris remains a challenge even for skilled and experienced physicians. Anginal headache may be induced by physical exercise or sexual intercourse (also commonly precipitants of both subarachnoid hemorrhage and migraine) but also can occur at rest, especially if it is the presenting symptom of acute myocardial infarction. Features that may help to distinguish the anginal basis of headache include the prompt disappearance of pain following administration of nitroglycerin, an intervention which usually triggers head pain in both healthy individuals and patients with ischemic heart disease, and the possible exacerbation of symptoms by triptan therapy. The latter may reflect the triptans potential to worsen myocardial ischemia because of the drugs’ vasoconstrictive activity. Regardless, the real key to accurate diagnosis is the close temporal association between headache and electrocardiographic changes characteristic of myocardial ischemia, which in turn reverse when head pain subsides; this feature has been well demonstrated through provacative stress tests.

The failure to recognize acute coronary syndromes in the emergency department is still a serious public health issue. A recent multicenter, prospective, clinical trial has reported that as many as 2.3% of patients with unstable angina and 2.1% of patients with an acute myocardial infarction were mistakenly discharged from the emergency department; presenting with atypical chest pain or other symptoms and being a young woman with no overt risk factors for ischemic heart disease added significantly to the probability of having a missed diagnosis of acute coronary syndrome. Those features match well with the demographic characteristics of the patient population evaluated in the study by Morgenstern and colleagues.

In our opinion, a workup including at least an electrocardiogram and measurement of blood levels of markers of myocardial injury should be regarded as mandatory for all patients who present to the emergency department with acute headache, especially in those with major risk factors for ischemic heart disease. When these test results are nondiagnostic but clinical suspicion is still high, patients should be admitted and provacative stress tests arranged.

The harmful consequences of overlooking the diagnosis of headache as an equivalent of angina pectoris are such that surveillance for this syndrome should be intensified. Available studies have not accurately defined its prevalence, and this first and crucial step will be required to calculate the cost-benefit ratio of the clinical management we suggest.