Characteristics of headache in vertebral artery dissections

Purpose

A vertebral artery dissection (VAD) is a rare disorder that can masquerade as musculoskeletal head and/or neck pain and requires urgent medical referral. If diagnosis is missed or mismanaged it can progress to stroke and death. Headaches are one of the main symptoms of a VAD that precedes ischaemic signs. The aim of this systematic review is to identify the common features of VAD headaches to ascertain if key characteristics can aid differentiation from other less sinister causes of headache with musculoskeletal origin.

Approach

Six databases (Cinahl plus, Web of Science, AMED, Medline, Cochrane and Sports Discus) were searched in January 2018. The search strategy was formulated in conjunction with a health librarian and included two search themes: vertebral artery dissection and clinical presentation. VADs resulting from trauma, post-partum, or in the carotid or intracranial arteries and children were excluded. Only cases reporting headaches were included. An independent researcher was used to verify the screening process with consensus meetings held to resolve disagreements. Articles were screened for risk of bias using the Joanna Briggs tool for case reports and case series.

 

Outcomes

Results: The searches yielded 1561 articles. Following screening, 24 remained, identifying 525 cases (55% (286) male; 45% (239) female), mean age: 41 yrs. Characteristics of headache were defined as: duration of headache prior to onset of ischaemic symptoms, location, intensity and behaviour. Of cases reporting the duration of headache prior to the onset of ischaemic symptoms, 43% (29) fell between 3.5 and 7 days and 42% (28) between 7.5 and 14 days. Of cases reporting the location of headache, the most common were 60% (67) occipital, 11%(12) nuchal and 10% (11) in the frontal region. Of cases reporting ipsi/contralateral locations, all (100%, 21) experienced pain ipsilateral to the side of the dissection. Where reported, pain intensity was described as “unbearable” (6%, 3), “severe” by 56% (30) and “responded to simple analgesics” by 20%(11). Where reported, the behaviour was either acute in 23% (16), continuous in 30% (21) or spreading in 17% (12). 27% (39) reported throbbing and 8% (11) stated “unlike anything experienced before”.

Conclusion(s): The results suggest that headaches associated with VADs are severe, often continuous and throbbing in nature, described as severe pain and mainly manifest in the occipital region. The headaches were shown to be present from 3-14 days prior to ischaemic symptoms, highlighting an opportunity for early recognition by clinicians in preventing an ischaemic event. Eight percent of participants described the pain as unique which, although a small proportion, should be borne in mind when differentiating the VAD headache with a previous history of headaches or migrain

Cost and savings

No further information. 

Implications

These findings create a profile for headaches related to VAD which can be used by healthcare professionals and for guideline development to aid differential diagnosis. However, it should be noted there was considerable variability in symptoms of the cases reported and headaches were often not presented in isolation therefore for a thorough patient assessment the whole presentation should be taken in account.

Top three learning points

No further information. 

Funding acknowledgements

No funding was received for this study.