Can a headache be a symptom of myocardial infarction (heart attack), especially in women, diabetics, and the elderly, or in patients with a history of cerebrovascular accident (stroke)?

Can Headache Be a Result of Myocardial Infarction?

Yes, headache can be a presenting symptom of myocardial infarction, particularly in women, elderly patients (>75 years), and those with diabetes or prior stroke, though it is uncommon and often leads to dangerous delays in diagnosis and treatment. 1, 2

High-Risk Populations for Atypical Presentations

Healthcare providers must maintain an extremely high index of suspicion for MI when evaluating specific patient groups who present with headache:

• Women: More likely to present with accompanying symptoms including jaw pain, neck pain, back pain, nausea, and diaphoresis alongside or instead of chest pain 1, 2
• Elderly patients (>75 years): May present with headache, syncope, acute delirium, unexplained falls, or generalized weakness rather than classic chest pain 1
• Diabetic patients: Atypical presentations occur due to autonomic dysfunction, making headache a possible sole manifestation 1, 2
• Patients with prior stroke: Should be evaluated with heightened suspicion for cardiac ischemia when presenting with headache 1

Clinical Characteristics of Cardiac Headache

When headache represents myocardial ischemia, specific patterns emerge:

• Exertional headache: Headache triggered by physical exercise or emotional stress suggests cardiac origin 3, 4
• Pressure-like quality: Described as pressure, tightness, or heaviness rather than sharp or stabbing 2, 3
• Associated symptoms: Accompanied by dyspnea, diaphoresis, nausea, epigastric pain, or palpitations 1, 2
• Thunderclap onset: Sudden, severe headache at rest has been reported as the sole symptom of acute MI 5
• Gradual onset: Headache building in intensity over minutes, similar to typical anginal symptoms 3, 6

Critical Mortality Data

The stakes of missing this diagnosis are extraordinarily high:

• One-third of all confirmed MIs present without chest discomfort 1
• Silent MI patients are 2.2 times more likely to die during hospitalization (23.3% vs 9.3% mortality) 1
• Mean delay to hospital is longer (7.9 vs 5.3 hours) when chest discomfort is absent 1
• Less likely to receive life-saving treatment: These patients receive fibrinolysis, PCI, aspirin, beta-blockers, and heparin less frequently 1

Immediate Diagnostic Approach

When headache occurs in at-risk patients, execute this algorithm:

1. Obtain immediate 12-lead ECG regardless of whether chest pain is present 2
2. Check cardiac biomarkers (troponin) in all patients with cardiovascular risk factors presenting with unexplained headache 2
3. Assess cardiovascular risk factors: hypertension, hyperlipidemia, diabetes, smoking, family history of premature CAD 1, 2
4. Place patient in monitored environment with continuous ECG monitoring and defibrillation capability 2
5. Do not rely on nitroglycerin response as a diagnostic criterion—relief with NTG does not confirm or exclude cardiac ischemia 1, 2

Mechanisms and Pathophysiology

The headache associated with MI likely represents referred pain from cardiac ischemia rather than a generalized vasospastic disorder 6. Women have a higher proportion of MI caused by non-classical mechanisms including plaque erosion, coronary microvascular dysfunction, coronary vasospasm, and spontaneous coronary artery dissection, which may contribute to atypical symptom presentations 2.

Critical Pitfalls to Avoid

• Never dismiss headache as neurological or musculoskeletal without excluding cardiac causes first, especially in women over 50, diabetics, and elderly patients 2, 3
• Do not evaluate suspected ACS solely over the telephone—patients must be referred to a facility allowing physician evaluation 1
• Traditional risk scores underestimate risk in women and frequently misclassify them as having nonischemic pain 1, 2
• Assuming headache requires exertional pattern—headache occurring at rest can represent unstable angina or acute MI 3, 5
• Failing to obtain ECG in high-risk populations presenting with isolated headache is a dangerous oversight 2

Case Evidence

Recent case series demonstrate that headache can be the sole presenting symptom of both acute MI and chronic coronary syndromes, with successful resolution following percutaneous revascularization 3. Cases include exertion-induced headaches from chronic total occlusion and acute headache preceding classic cardiac symptoms in acute coronary occlusion 3. Elderly patients over 80 years have presented with severe, acute headache as the only manifestation of MI 7.