Headache as the sole presenting symptom of acute myocardial infarction.

www.japi.org 83 Headache as the Sole Presenting Symptom of Acute Myocardial Infarction Sir, The International Classification of Headache Disorders does not include Acute Myocardial Infarction (AMI) or Acute Coronary Syndrome (ACS) as one of the rare causes of headache.1 On review of the literature it has been observed that it is very rare for patients with AMI or ACS to present with headache as the sole symptom. We had a patient admitted to our hospital with headache as the only complaint for AMI. A 48 years male, ht.163 cm, wt. 66 kg., old hypertensive continuing regularly atenolol 50 mg daily for 1 week reported to emergency department at 11.25 pm on 08/02/07 with intermittent severe headache of 2 hours duration. The headache was located in bitemporal regions, explosive in nature, not relieved by any measure but increased on exertion. There was no history of vomiting and fever. He was non-diabetic. He had bouts of headache during the past one month which was relieved by rest. He correlated his headache to a trivial blunt injury to the head about 2 years back. He also had an episode of apprehension 5 days back associated with perspiration. On admission, he was conscious, oriented, afebrile, pulse 68/min., regular, BP 150/100 mm of Hg. Systemic examination did not reveal any abnormality. On the provisional diagnosis of tension headache or migraine he was treated with clonazepam 0.5 mg, nimesulide 100 mg and atenolol 50 mg. Emergency investigations were done which showed Hb 15.0 g/dl, ESR 02 mm 1st hour, TLC 9,200/cumm, P 69, L 24, E 6, M 1, RBS 120 mg/dl, Urine albumin – trace, sugar-nil, occasional calcium oxalate crystals, ECG : Normal (Fig. 1a). On the next day (09/02/07) his headache persisted and he was restless. BP 160/100 mm of Hg, pulse 80/min, regular, systemic examination did not reveal any abnormality. He was treated with tablet propranolol 10 mg 8 hourly, flunarizine 10 mg daily, aciclofenac 100 mg and paracetamol 500 mg. His PPBS 130 mg/dl, total cholesterol 208 mg/dl, triglyceride 122 mg/dl, HDL-c 42mg/dl, LDL-c 142 mg/dl, blood urea 23 mg/dl, creatinine 1.3 mg/dl, CPK-NAC 824 u/L (30-170 u/L), CPK-MB 54 u/L (0-24 u/L), LDH 442 u/L (upto 450 u/L), SGOT 39 u/L, Troponin – T was negative, SGPT 46 u/L, alk phos 58 u/L, Na 140 mm01/L, K 4.7 mm01/L. X-ray PNS – normal. On 10/02/07, he was still having headache and could not sleep. CT scan head was done and reported to be normal. His condition remained same without improvement. Headache persisted, he had sweating and sleepless night. Since his CPK-MB was high on 09/02/07, ECG was repeated at 7.45 AM on 12/02/07 which showed ST elevation in V3 to V5 leads indicating acute anteroseptal infarct (Fig. 1b). Cardiac enzymes were repeated to show CPK NAC 793 u/L, CPK MB 47 u/L, SGOT 97 u/L, LDH 1603 u/L and Troponin Correspondence