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6.9:
Headache associated with other vascular disorder
Headaches
may be associated with hypotension. Not uncommonly, individuals who
complain of headache are found to have unusually low blood pressure
readings. We have observed such individuals who complained of
generalized headaches that usually appeared late in the afternoon and
were not particularly severe. It is difficult to assess the significance
of headache in such persons just as it is difficult to estimate the
significance of vascular hypotension. Postural hypotension with a
significant drop in blood pressure may be associated with a headache,
the symptoms of which usually correlate with the positional change.
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Postendarterectomy
headache |
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Raskin
(1988) describes another separate type of headache occurring in
individuals having recently had a carotid endarterectomy. An intense
vascular headache, usually ipsilateral to the operated internal carotid
artery, may appear soon after carotid endarterectomy (Pearce, 1976).
There is usually a headache-free interval of 36 to 72 hours after which
a syndrome begins that may be very similar to migraine. Focal neurologic
symptoms may precede headache, which is usually anterior in location,
pounding in quality, and of brief duration, usually lasting 1 to 3
hours. Nausea often accompanies the syndrome, which may be triggered by
rapid postural change, the ingestion of alcohol, or exposure to glare.
The focal symptoms are usually referable to the cerebral hemisphere
ipsilateral to the endarterectomy site. The condition is ultimately
benign and self-limited, but may persist for several months. Carotid
angiography performed at the time of a severe headache showed a normal
carotid arterial circulation (Leviton et al, 1975). Messert and Black
(1978) have shown that this disorder is not at all uncommon; headache
appearing 2 days after carotid endarterectomy occurred in 21 or 50
consecutive patients who underwent the procedure. Of these 21 patients,
10 developed diffuse, poorly characterized headache of variable
intensity and 11 developed severe headache with a prominent retrobulbar
component ipsilateral to the surgical site; 5 had strictly hemicranial
pain. Fisher (1984) has found that corticosteroids are remarkably
effective in treating this disorder. The condition of one patient with
both severe hypertension and headaches following endarterectomy was
promptly improved following treatment with prazosin (Dolan and Mushlin,
1984).
In view
of the manipulation of the common carotid artery, its adventitia, and
the carotid sinus during this procedure, it is perhaps surprising that
the headache does not occur more often after endarterectomy. The
mechanism of the latent interval and the syndrome itself is not clear.
The sudden distention of arterial walls previously protected by stenosis
is a reasonable explanation for the headache, but does not take into
account the latent interval. A disturbance of cerebral arterial
autoregulation has been suggested by Leviton et al (1975), and Sundt et
al (1981) and Reigel et al (1987) have provided supportive data. These
authors found that postoperative CBF increases to more than 200 percent
of baseline flow, presumably because of defective autoregulation,
correlated with postoperative headache, seizures, and cerebral
hemorrhages.
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