Recurrent Cardiac Cephalalgia

Introduction: Cardiac cephalalgia is a headache disorder associated with myocardial ischemia that presents as a moderate to severe exertional headache with potentially migrainous features that remains difficult to identify due to highly variable presentations and unclear pathophysiology. Case Report: We present a diagnostically challenging case of cardiac cephalalgia in an elderly male with multiple cardiovascular risk factors and a remote history of percutaneous coronary intervention (PCI) for coronary artery disease (CAD), exemplified by a multiyear history of progressive exertional headaches without stereotypical cardiac symptoms, normal brain imaging, an unremarkable neurological exam, and the presence of a confounding SIADH. In an exceedingly rare event in the reported literature, this patient returned in the same year after treatment with a recurrence of symptoms. Conclusions: Given the heterogeneity in presentation of cardiac cephalalgia, accurate and efficient diagnosis remains challenging, especially in cases with isolated cephalalgia, but case reports such as this highlight the need for vigilance in history taking, examination, and work-up to identify a potentially lethal cardiovascular emergency underlying this type of headache. While the presentation varies widely, cardiac cephalalgia most commonly presents in older males as a severe, exertional, pressure-like headache in the frontal region, associated with angina but without autonomic features.