Headache and neck pain in spontaneous internal carotid and vertebral artery dissections

Abstract

We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.

Primary headaches and painful spontaneous cervical artery dissection

“…This agrees with previous studies [4][5][6][7][8]. In ICAD patients, pain was significantly more frequent in the anterior part of the head, compared to VAD, where pain occurred in the nuchal and/or occipital region.…”

“…In ICAD patients, pain was significantly more frequent in the anterior part of the head, compared to VAD, where pain occurred in the nuchal and/or occipital region. The anterior location of the pain in ICAD may be explained by stretch, distortion and ischemia of the pericarotid plexus and the posterior location of the pain in VAD may be due to lesion of upper cervical nerves involved to the perivascular innervations of the arteries of the posterior fossa [5]. Both routes converge into the trigeminovascular system, implied in the referral of vascular pain (visceral inputs) to superficial tissues (somatic forehead inputs).…”

“…This time was set arbitrarily, according to Silbert et al [5], to exclude stroke-related pain. We calculated the "pain-to-stroke time" as the time between the onset of pain that started and remained continuous or was present daily, and the onset of the IE.…”

“…Headache, facial or neck pain are common presenting symptoms of SCAD, although mechanisms underlying dissection-related pain remains incompletely understood [4][5][6][7][8]. The relationship between previous migraine and painful SCAD was investigated in only two studies with opposite findings and therefore it is still a matter of controversy [4,5].…”

“…Improvement in migraine and tension-type headache (TTH) after SCAD have been reported [5,9,10], however the possible interference of the use of prophylactic drugs has not been assessed.…”