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Syncope and Headache

  • Ramesh K. Khurana
Secondary Headache (M Robbins, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Secondary Headache

Abstract

Purpose of Review

We review the literature on co-occurrence of syncope and headache and share clinical experience.

Recent Findings

Headache in relation to syncope has been the subject of recent interest.

Summary

Orthostatic intolerance has an expanding spectrum with three well-defined entities: orthostatic hypotension (OH), neurally mediated hypotension (NMH), and postural tachycardia syndrome (PoTS). Syncope occurs in patients with OH as well as in patients with episodically occurring NMH. Headache of OH is called coat-hanger ache (CHA) because it affects the neck and shoulders in a coat-hanger pattern. It can serve as a warning symptom of OH as well as a parameter to gauge the benefit of treatment. Awareness of CHA avoids inappropriate tests. Headache type occurring in NMH has not been fully delineated. A questionnaire-based study describes migraine leading to syncope and treatment of migraine to reduce syncope. Laboratory studies in NMH patients provide evidence for only short-duration headache. The author’s approach to such patients is presented.

Keywords

Baroreflex Orthostatic hypotension Reflex syncope Neurally mediated hypotension Coat-hanger ache 

Notes

Compliance with Ethical Standards

Conflict of Interest

Ramesh K. Khurana declares no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.

References

  1. 1.
    Benarroch EE. The arterial baroreflex: functional organization and involvement in neurologic disease. Neurology. 2008;71:1733–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21:69–72.CrossRefPubMedGoogle Scholar
  3. 3.
    Gibbons CH, Freeman R. Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance. Neurology. 2006;67:28–32.CrossRefPubMedGoogle Scholar
  4. 4.
    Convertino VA. Neurohumoral mechanisms associated with orthostasis: reaffirmation of the significant contribution of the heart rate response. Front Physiol. 2014;5:236.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Schroeder C, Jordan J, Kaufmann H. Management of neurogenic orthostatic hypotension in patients with autonomic failure. Drugs. 2013;73:1267–79.CrossRefPubMedGoogle Scholar
  6. 6.
    Low PA. Prevalence of orthostatic hypotension. Clin Auton Res. 2008;18(Suppl 1):8–13.CrossRefPubMedGoogle Scholar
  7. 7.
    Rutan GH, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS. Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group. Hypertension. 1992;19:508–19.CrossRefPubMedGoogle Scholar
  8. 8.
    Low PA, Opfer-Gehrking TL, McPhee BR, et al. Prospective evaluation of clinical characteristics of orthostatic hypotension. Mayo Clin Proc. 1995;70:617–22.CrossRefPubMedGoogle Scholar
  9. 9.
    Arbogast SD, Alshekhlee A, Hussain Z, McNeeley K, Chelimsky TC. Hypotension unawareness in profound orthostatic hypotension. Am J Med. 2009;122:574–80.CrossRefPubMedGoogle Scholar
  10. 10.
    Kaufmann H, Malamut R, Norcliffe-Kaufmann L, Rosa K, Freeman R. The orthostatic hypotension questionnaire (OHQ): validation of a novel symptom assessment scale. Clin Auton Res. 2012;22:79–90.CrossRefPubMedGoogle Scholar
  11. 11.
    Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30:2631–71.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Gugger JJ. Antipsychotic pharmacotherapy and orthostatic hypotension: identification and management. CNS Drugs. 2011;25:659–71.CrossRefPubMedGoogle Scholar
  13. 13.
    Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347:878–85.CrossRefPubMedGoogle Scholar
  14. 14.
    Ganzeboom KS, Colman N, Reitsma JB, Shen WK, Wieling W. Prevalence and triggers of syncope in medical students. Am J Cardiol. 2003;91:1006–8. A8CrossRefPubMedGoogle Scholar
  15. 15.
    Wieling W, Thijs RD, van DN WAA, Benditt DG, van Dijk JG. Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain. 2009;132:2630–42.CrossRefPubMedGoogle Scholar
  16. 16.
    Lempert T, Bauer M, Schmidt D. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol. 1994;36:233–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Stewart JM. Common syndromes of orthostatic intolerance. Pediatrics. 2013;131:968–80.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Khurana RK. Initial orthostatic and non-orthostatic hypotension in wrestler’s syncope. Clin Auton Res. 2017;27:423–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Khurana RK. Eye examination-induced syncope role of trigeminal afferents. Clin Auton Res. 2002;12:399–403.CrossRefPubMedGoogle Scholar
  20. 20.
    Khurana RK. Orthostatic intolerance and orthostatic tachycardia: a heterogeneous disorder. Clin Auton Res. 1995;5:12–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Khurana RK, Eisenberg L. Orthostatic and non-orthostatic headache in postural tachycardia syndrome. Cephalalgia. 2011;31:409–15.CrossRefPubMedGoogle Scholar
  22. 22.
    Chew EM, Allen EV, Barker NW. Orthostatic hypotension: report of six cases and review of the literature. Northwest Med. 1936;35:297–303.Google Scholar
  23. 23.
    Robertson D, Robertson M. Orthostatic hypotension: diagnosis. Mod Concepts Cardiovasc Dis. 1985;54:7–12.Google Scholar
  24. 24.
    Robertson D, Kincaid DW, Haile V, Robertson RM. The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache. Clin Auton Res. 1994;4:99–103.CrossRefPubMedGoogle Scholar
  25. 25.
    Bleasdale-Barr KM, Mathias CJ. Neck and other muscle pains in autonomic failure: their association with orthostatic hypotension. J R Soc Med. 1998;91:355–9.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Khurana RK. Coat-hanger ache in orthostatic hypotension. Cephalalgia. 2012;32:731–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Kaufmann H, Freeman R, Biaggioni I, Low P, Pedder S, Hewitt LA, et al. Droxidopa for neurogenic orthostatic hypotension: a randomized, placebo-controlled, phase 3 trial. Neurology. 2014;83:328–35.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Humm AM, Bostock H, Troller R, Z'Graggen WJ. Muscle ischaemia in patients with orthostatic hypotension assessed by velocity recovery cycles. J Neurol Neurosurg Psychiatry. 2011;82:1394–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Headache Classification Committee of the International Headache Society. The international classification of headache disorders; 3rd ed. (beta version). Cephalgia. 2013;33:629–808.CrossRefGoogle Scholar
  30. 30.
    Smith MS, Glass ST. An adolescent girl with headache and syncope. J Adolesc Health Care. 1989;10:54–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Paisley RD, Arora HS, Nazeri A, Massumi A, Razavi M. Migraine and vasodepressor syncope in a large family. Tex Heart Inst J. 2009;36:468–9.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Daas A, Mimouni-Bloch A, Rosenthal S, Shuper A. Familial vasovagal syncope associated with migraine. Pediatr Neurol. 2009;40:27–30.CrossRefPubMedGoogle Scholar
  33. 33.
    Selby G, LANCE JW. Observations on 500 cases of migraine and allied vascular headache. J Neurol Neurosurg Psychiatry. 1960;23:23–32.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Thijs RD, Kruit MC, van Buchem MA, Ferrari MD, Launer LJ, van Dijk JG. Syncope in migraine: the population-based CAMERA study. Neurology. 2006;66:1034–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Curfman D, Chilungu M, Daroff RB, Alshekhlee A, Chelimsky G, Chelimsky TC. Syncopal migraine. Clin Auton Res. 2012;22:17–23.CrossRefPubMedGoogle Scholar
  36. 36.
    Vallejo M, Martinez-Martinez LA, Grijalva-Quijada S, et al. Frequency of migraine in patients with vasovagal syncope. Int J Cardiol. 2014;171:e14–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Ocon AJ, Messer Z, Medow MS, Stewart JM. Increased pulsatile cerebral blood flow, cerebral vasodilation, and postsyncopal headache in adolescents. J Pediatr. 2011;159:656–62.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Khurana RK, Van Meerbeke S. Headache of neurally mediated syncope. Cephalalgia. 2016;36:1350–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Blau JN. Syncope, vomiting, and migraine. Lancet. 1988;2:626.CrossRefPubMedGoogle Scholar
  40. 40.
    Manne JR. Cluster syncope. Am J Med. 2016;129:e13–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Alexandre J, Humbert X, Sassier M, Milliez P, Coquerel A, Fedrizzi S. High-dose verapamil in episodic and chronic cluster headaches and cardiac adverse events: is it as safe as we think? Drug Saf Case Rep. 2015;2:13.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    den Hartog AW, Jansen E, Kal JE, Duyndam D, Visser J, van den Munckhof P, et al. Recurrent syncope due to glossopharyngeal neuralgia. HeartRhythm Case Rep. 2017;3:73–7.CrossRefGoogle Scholar
  43. 43.
    Kapoor WN, Jannetta PJ. Trigeminal neuralgia associated with seizure and syncope. Case report. J Neurosurg. 1984;61:594–5.CrossRefPubMedGoogle Scholar
  44. 44.
    Hoefnagels WA, Padberg GW, Overweg J, van der Velde EA, Roos RA. Transient loss of consciousness: the value of the history for distinguishing seizure from syncope. J Neurol. 1991;238:39–43.CrossRefPubMedGoogle Scholar
  45. 45.
    Khurana RK. Dysautonomia. In: Schuster MM, Crowell MD, Koch KL, editors. Schuster atlas of gastrointestinal motility. Hamilton: BC Decker, Inc.; 2002. p. 335–51.Google Scholar
  46. 46.
    Kirchmann M, Thomsen LL, Olesen J. Basilar-type migraine: clinical, epidemiologic, and genetic features. Neurology. 2006;66:880–6.CrossRefPubMedGoogle Scholar
  47. 47.
    Starling AJ. Diagnosis and management of headache in older adults. Mayo Clin Proc. 2018;93:252–62.CrossRefPubMedGoogle Scholar
  48. 48.
    Call GK, Fleming MC, Sealfon S, Levine H, Kistler JP, Fisher CM. Reversible cerebral segmental vasoconstriction. Stroke. 1988;19:1159–70.CrossRefPubMedGoogle Scholar
  49. 49.
    Keles A, Demircan A, Kurtoglu G. Carbon monoxide poisoning: how many patients do we miss? Eur J Emerg Med. 2008;15:154–7.CrossRefPubMedGoogle Scholar
  50. 50.
    Lansen TA, Kasoff SS, Vingiano W. Headache characteristics in aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis. 1993;3:216–21.CrossRefPubMedGoogle Scholar
  51. 51.
    Lowenstein DH, Massa SM, Rowbotham MC, Collins SD, McKinney HE, Simon RP. Acute neurologic and psychiatric complications associated with cocaine abuse. Am J Med. 1987;83:841–6.CrossRefPubMedGoogle Scholar
  52. 52.
    Thadani U, Rodgers T. Side effects of using nitrates to treat angina. Expert Opin Drug Saf. 2006;5:667–74.CrossRefPubMedGoogle Scholar
  53. 53.
    Two A, Christian E, Mathew A, Giannotta S, Zada G. Giant, calcified colloid cyst of the lateral ventricle. J Clin Neurosci. 2016;24:6–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Williams B. Chronic herniation of the hindbrain. Ann R Coll Surg Engl. 1981;63:9–17.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Smith JH, Butterfield JH, Pardanani A, DeLuca GC, Cutrer FM. Neurologic symptoms and diagnosis in adults with mast cell disease. Clin Neurol Neurosurg. 2011;113:570–4.CrossRefPubMedGoogle Scholar
  56. 56.
    Zhai H, Ma X, Nie W, Li H, Peng C, Li X, et al. Paraganglioma of the urinary bladder: a series of 22 cases in a single center. Clin Genitourin Cancer. 2017;15:e765–71.CrossRefPubMedGoogle Scholar
  57. 57.
    Khurana RK, Russell C. The spoon test: a valid and reliable bedside test to assess sudomotor function. Clin Auton Res. 2017;27:91–5.CrossRefPubMedGoogle Scholar
  58. 58.
    Cheshire WP, Goldstein DS. The physical examination as a window into autonomic disorders. Clin Auton Res. 2018;28:23–33.CrossRefPubMedGoogle Scholar
  59. 59.
    Khurana RK, Nicholas EM. Head-up tilt table test: how far and how long? Clin Auton Res. 1996;6:335–41.CrossRefPubMedGoogle Scholar
  60. 60.
    Gurevich T, Machmid H, Klepikov D, Ezra A, Giladi N, Peretz C. Head-up tilt testing for detecting orthostatic hypotension: how long do we need to wait? Neuroepidemiology. 2014;43:239–43.CrossRefPubMedGoogle Scholar
  61. 61.
    Jones PK, Shaw BH, Raj SR. Orthostatic hypotension: managing a difficult problem. Expert Rev Cardiovasc Ther. 2015;13:1263–76.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Schleifer JW, Shen WK. Vasovagal syncope: an update on the latest pharmacological therapies. Expert Opin Pharmacother. 2015;16:501–13.CrossRefPubMedGoogle Scholar
  63. 63.
    Shibao C, Lipsitz LA, Biaggioni I. ASH position paper: evaluation and treatment of orthostatic hypotension. J Clin Hypertens (Greenwich). 2013;15:147–53.CrossRefGoogle Scholar
  64. 64.
    Smeenk HE, Koster MJ, Faaij RA, de Geer DB, Hamaker ME. Compression therapy in patients with orthostatic hypotension: a systematic review. Neth J Med. 2014;72:80–5.PubMedGoogle Scholar
  65. 65.
    May M, Jordan J. The osmopressor response to water drinking. Am J Phys Regul Integr Comp Phys. 2011;300:R40–6.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of MedicineMedStar Union Memorial HospitalBaltimoreUSA

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