Headache secondary to cervical artery dissections: practice pointers

Abstract

Cervical artery dissections may present with mild and misleading symptoms such as a headache or cervical pain. In the absence of early diagnosis and therapy, such patients may have a high risk of cerebrovascular events. In order to refine evaluation of cervical artery dissections, we report the experience of a single center, focusing on clinical findings (e.g., headache and pain-related features at onset). From 2012 to 2017, 49 patients with cervical arteries dissections were admitted to our institution; 28 out of 49 patients (57%) presented with a headache or cervical pain, which were evaluated according to the International Classification of Headache Disorders (ICHD-III beta). Item C3a of ICHD-III beta ("pain is severe and continuous for days or longer") was present in all patients symptomatic for a headache. Another common characteristic was the recent onset, with an average (± SD) timing from the onset of a headache to the first neurologic evaluation of 3 (± 2) days (range 1-5). A refined clinical evaluation of patients presenting with a headache at the Emergency Department could improve the early detection and management of patients with cervical artery dissections, in particular when presenting without other associated neurological symptoms.

Spontaneous Carotid Artery Dissection Presenting as Trigeminal Neuralgia in the Emergency Department

“…3 Recent-onset unilateral headaches with continuous pain have been considered the most important paucisymptomatic of cervical (vertebral and carotid) artery dissections. 4 The diagnostic criteria for headache attributed to cervical artery dissection includes two of the following: temporal pain that evolves to encompass other signs of cervical artery dissection; pain that improves/ resolves after one month of onset or worsens contemporarily with other signs of cervical arterial lesions; pain that is severe and continues for days (most sensitive finding) or precedes signs of acute retinal/cerebral ischemia; and/or pain that is unilateral and ipsilateral to dissected cervical artery. 4 Unilateral neck pain is seen in about 25% of patients, and unilateral facial/orbital pain in about 50% of patients.…”

“…4 The diagnostic criteria for headache attributed to cervical artery dissection includes two of the following: temporal pain that evolves to encompass other signs of cervical artery dissection; pain that improves/ resolves after one month of onset or worsens contemporarily with other signs of cervical arterial lesions; pain that is severe and continues for days (most sensitive finding) or precedes signs of acute retinal/cerebral ischemia; and/or pain that is unilateral and ipsilateral to dissected cervical artery. 4 Unilateral neck pain is seen in about 25% of patients, and unilateral facial/orbital pain in about 50% of patients. 3 Approximately 10% of pain is isolated to the face or neck; most pain will progress to a unilateral headache in the temporal and frontal regions.…”

Headache in cerebrovascular diseases

“…Headache is often acute and continuous for days or longer, and located at the same side of the affected cervical vessel. If the patient only suffers from neck pain, the degree is often mild to moderate, and if he has headache with or without neck pain, the intensity is usually moderate to severe 13. Headache is more common in posterior circulation stroke than in anterior circulation, and the reasons have been speculated as follows.…”

“…If the patient only suffers from neck pain, the degree is often mild to moderate, and if he has headache with or without neck pain, the intensity is usually moderate to severe. 13 Headache is more common in posterior circulation stroke than in anterior circulation, and the reasons have been speculated as follows. First, there are more dense vessels and abundant trigeminal nerve distribution in the posterior circulation system; second, the posterior cerebral arteries and superior cerebellar arteries supply part of the dura mater; third, the posterior circulation vessels might be more susceptible to spreading depolarisations.…”

Three-Dimensional High-Resolution Magnetic Resonance Imaging for the Assessment of Cervical Artery Dissection

“…The difficulties in the diagnosis of CAD have been well-documented in many previous studies ( Robertson and Koyfman, 2017 ; Markus et al, 2019 ). Its clinical symptoms are often non-specific ( Gallerini et al, 2019 ). Digital subtraction angiography (DSA), which was regarded as the gold standard for luminal imaging before magnetic resonance imaging (MRI), is no longer recommended for the diagnosis of CAD, not only because of its invasive nature but also because it lacks the ability to visualize the vessel wall ( Debette and Leys, 2009 ).…”