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Abstract
Myocardial ischaemia typically causes chest pain, variously radiating elsewhere. Occasionally, cardiac pain can only be referred to regions outside the thorax such as the neck, jaw, epigastrium, and arms.1 Headache is a rare symptom of myocardial ischaemia. When present it is often associated with typical angina (table). In this patient, headache was the only symptom of myocardial ischaemia. Anatomic convergence of cardiac nerve fibres on central pathways receiving somatic afferent from the head is likely to be responsible for the perception of cardiac ischaemic pain as headache. This patient had an unstable coronary syndrome, with angiographically diagnosed extensive coronary artery disease, and a small non-Q-wave myocardial infarction. The association of cardiac headache with severe coronary artery disease has been previously reported.2-5 In patients with milder forms of coronary artery disease, a cardiac origin of headache may remain undetected. Owing to the very rare occurrence of headache as a symptom of myocardial ischaemia, diagnosis is difficult and requires a high degree of suspicion. The site of cardiac headache is not specific (table), accordingly physicians should consider a cardiac origin of a headache when it is episodic, lasts only a few minutes, and regresses spontaneously, particularly in patients with cardiovascular risk factors.