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To the Editor.—
In the article "Bregmatic Headache as a Manifestation of Myocardial Ischemia" (Archives 1982;39:130), Drs Lefkowitz and Biller describe an interesting and well-known but uncommon clinical symptom of sudden, severe, "explosive" evanescent cranial pain. They suggest that in their patient because of the temporal relationships and rapid dissolution with nitroglycerin, the pain felt in the head was a referred one and an unusual manifestation of myocardial ischemia.A more likely explanation has occurred to me. During attacks of angina, patients often gasp for breath, perform involuntary Valsalva maneuvers, and there are changes in pulmonary and intrathoracic pressures and cardiac compliance. This in turn causes rapid, fleeting intracranial hypertension by (1) a pressure wave via the thoracic-vertebral venous channels and (2) by altering venous out-flow from the intracranial sinuses, leading to rapid transient dilation of these sinuses that are richly innervated by pain-mediating fibers from the trigeminal, facial
Daniels JC. Myocardial Ischemia Manifestation. Arch Neurol. 1982;39(9):602–603. doi:10.1001/archneur.1982.00510210072029
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