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.

Postendarterectomy headache

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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