You-Cai Bi,Department of Neurology,Zigong Fourth People’s Hospital,Zigong 643000,Sichuan Province,China

Liang Gong,Department of Neurology,Chengdu Second People’s Hospital,Chengdu 650017,Sichuan Province,China

Abstract

Key words:Headache;Palpitations;Sick sinus syndrome;Differential diagnosis;Case report;Electrocardiogram

INTRODUCTION

Headache is a common neurological symptom with a multitude of different causes such as intracranial hemorrhage,infection,and migraine.Sick sinus syndrome is an arrhythmia phenotype attributed to sinus node dysfunction.The clinical symptoms of sick sinus syndrome include palpitations,dizziness,chest tightness,weakness,shortness of breath,amaurosis,and Adams-Stokes syndrome,among others.In this report,we describe a case of headache induced by sick sinus syndrome.

CASE PRESENTATION

Chief complaints

On July 30,2018,a 73-year-old female patient presented to our department with the chief complaint of recurrent paroxysmal headache for more than 7 years.

History of present illness

The headaches lasted from minutes to hours,and presented with moderate swelling and recurrent paroxysmal pain through the whole brain.The patient had paroxysmal palpations as well,usually followed by the headache episodes.However,headaches did not always occur every time after palpations.The patient’s blood pressure was normal when the headaches occurred.

例如：教師可以運用多樣化的跳繩方式，例如甩大繩，多人一起參加，讓兩個人甩繩的方式來開展跳繩活動，這樣的跳繩運動不僅加強了學(xué)生的體育健康素養(yǎng)知識，又調(diào)動了學(xué)生的思考能力，鍛煉了學(xué)生的肢體協(xié)調(diào)性，讓學(xué)生對體育大課間活動更加感興趣。教師還可以指導(dǎo)學(xué)生采用“雙人跳”的方式，對于忘記帶跳繩的同學(xué)可以和其他同學(xué)一起完成跳繩運動，可以是背對著、面對著等方法一起跳，可以引發(fā)大腦的思考，也可以調(diào)動學(xué)生學(xué)習(xí)新鮮事物的興趣，調(diào)動學(xué)生的積極性。我們應(yīng)積極通過豐富多彩的跳繩運動來豐富學(xué)校生活，讓學(xué)生更主動地投入到大課間活動，而不再是“課上聽講、課下趴桌子睡覺”的狀態(tài)。

History of past illness

The patient has documented hypertension and type 2 diabetes,although blood pressure and glucose were well managed.

Personal and family history

The patient’s family history was unremarkable.

Physical examination

The patient′s heart auscultation was absolutely arrhythmic,heart sound intensities differed,and her pulse was deficient.Her blood pressure was 132/75 mmHg.The clinical neurological examination was negative.

Laboratory examinations

The patient′s thyroid function was normal.The liver and kidney function examination was also negative.

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Imaging examinations

A magnetic resonance imaging study and magnetic resonance angiography of the head performed at another center were normal (Figure1).

Electrocardiogram findings

The 24-h Holter electrocardiogram (ECG) monitoring study showed sinus bradycardia,sinus pause,AV junctional escape beats,ventricular escape,paroxysmal atrial flutter,and paroxysmal atrial fibrillation.The longest RR interval was 5.952 s(Figure2).

FINAL DIAGNOSIS

We arrived at a final diagnosis of sick sinus syndrome.

TREATMENT

The patient received dual-chamber pacing implantation on August 6,2018.The patient was prescribed Metoprolol Succinate Sustained-Release Tablets 47.5 mg twice a day and Amiodarone Hydrochloride Tablets once a day to control ventricular rate.

OUTCOME AND FOLLOW-UP

The patient’s paroxysmal headaches and palpitations had resolved within 1 year,confirmed by a follow-up telephone call.The ECG was normal after implantation of dual-chamber pacing (Figure3).

DISCUSSION

In this case,the organic lesion had not been considered when auxiliary examinations and a clinical neurological examination were both negative.Migraine was not considered on account of the patient’s age.When the patient described headaches following palpitations,we hypothesized that the headaches may have been related to an arrhythmia.After dual-chamber pacing implantation and pharmaceutical antiarrhythmic therapy,the patient was followed upviaa telephone call at 1 year.At that time,the patient reported resolution of her symptoms.Therefore,we believe that her headaches were related to sick sinus syndrome.

Common mechanisms of headache include:(1) Constriction,dilatation and extension of intracranial blood vessels caused by various pathologies;(2) Cranial and cervical nerve stimulation;(3) Elevated resting tension of the head and neck muscles;(4) Ophthalmologic and otorhinolaryngologic disorders,and cervical spine disease;(5) Biochemical factors and endocrine disorders;and (6) Neurological disorders.

Figure2 Twenty-four-hour Holter electrocardiogram monitoring results.

The incidence of headache as a symptom of sick sinus syndrome was not definite.No similar report was found in the literature.

Asvestaset al[1]reported a case of headache as a primary symptom of acute myocardial infarction.Huanget al[2]reported a similar case of a patient,who had been diagnosed with myocardial infarction and complained of headache without chest discomfort.Furthermore there have been multiple case reports of headache as the sole or cardinal symptom of myocardial infarction[3-6].Thus,the concept of headache being induced by cardiac factors has been presented.

Cardiac cephalgia is defined in The International Classification of Headache Disorders:2ndedition[7]and The International Classification of Headache Disorders:3rdedition[8,9].

There are four theories regarding the proposed pathogenesis of cardiac cephalgia.First,the heart is mediated by the autonomic nerve,visceral,and somatic fibers,which can converge on the same neurons in the spinal cord.Then the information induced by visceral afferents is relayed to the higher somatic region.Second,the reduction of cardiac output elevates left ventricular and right atrial pressure,which decreases cerebral venous refluxing and elevates intracranial pressure[10,11].Third,neurochemical mediators produced by myocardial ischemia can induce vasodilatation of the cerebral vessels and pain[10,11].Fourth,it is assumed that vasospasms can concomitantly occur in both coronary and cerebral vessels[10,12].

In this case,we hypothesized that arrhythmia led to myocardial ischemic and reduction of cardiac output.As a result of the arrhythmias,headache could be induced by stimulating visceral nerves and neurochemical mediators because of myocardial ischemia,and could also be induced by elevated intracranial pressure because of the reduction of cardiac output.Unfortunately,we did not monitor the variation of this patient’s cardiac output;thus,the possibility of other causes remains to be considered.

CONCLUSION

This case provides two novel insights.First,clinicians should pay close attention to predisposing symptoms and conditions.Second,it appears that arrhythmias can cause headaches.

Figure3 Electrocardiogram after implantation of dual-chamber pacing.

ACKNOWLEDGEMENTS

We thank the cardiologist for the expiation for the ECG.