ArticlePublisher preview availableLiterature Review

Neurological Causes of Chest Pain

May 2021
Current Pain and Headache Reports 25(5)

DOI:10.1007/s11916-021-00944-5

Authors:

Purpose of Review Chest pain is a very common presenting complaint among patients in the hospital, a large proportion of whom have non-cardiac chest pain (NCCP). Neurological causes of NCCP have not been previously reviewed although several causes have been identified. Recent Findings Chest pain has been reported as a symptom of multiple neurological conditions such as migraine, epilepsy, and multiple sclerosis, with varying clinical presentations. The affected patients are often not formally diagnosed for long periods of time due to difficulties in recognizing the symptoms as part of neurological disease processes. Summary This paper will briefly summarize well-known etiologies of chest pain and, then, review neurological causes of NCCP, providing an overview of current literature and possible pathophysiologic mechanisms.

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SECONDARY HEADACHE (M ROBBINS, SECTION EDITOR)

Neurological Causes of Chest Pain

Ushna Khan

&Matthew S. Robbins

Accepted: 12 February 2021

#The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021

Abstract

Purpose of Review Chest pain is a very common presenting complaint among patients in the hospital, a large proportion of whom

have non-cardiac chest pain (NCCP). Neurological causes of NCCP have not been previously reviewed although several causes

have been identified.

Recent Findings Chest pain has been reported as a symptom of multiple neurological conditions such as migraine, epilepsy, and

multiple sclerosis, with varying clinical presentations. The affected patients are often not formally diagnosed for long periods of

time due to difficulties in recognizing the symptoms as part of neurological disease processes.

Summary This paper will briefly summarize well-known etiologies of chest pain and, then, review neurological causes of NCCP,

providing an overview of current literature and possible pathophysiologic mechanisms.

Keywords Noncardiac chest pain .Neurologic pain .Migraine .Multiple sclerosis .Epilepsy .Guillain-Barré syndrome

Introduction

Chest pain is a very common presenting complaint in the

hospital. In the USA, it accounts for approximately 7 million

emergency department visits per year [1]. It is critical to rule

out life-threatening causes such as acute coronary syndrome

(ACS), pulmonary embolism, and aortic dissection [2].

However, these account for only a small portion of emergency

department visits for chest pain. Through analysis of a United

States database of emergency department visits, Hsia et al.

found that, of those presenting with a primary complaint of

chest pain, 5.5% of chest pain diagnoses reflected these life-

threatening causes, while 51.7% of diagnoses were catego-

rized as non-specific [3].

Non-cardiac chest pain (NCCP) is recognized as angina

pectoris-like chest pain in the absence of coronary heart dis-

ease [4]. However, there is no standard definition due to the

varying clinical features of this condition [5]. The epidemiol-

ogy of NCCP in the USA has not been well studied. Locke

et al. estimated the prevalence to be 23.1% based on question-

naires distributed in Olmstead County, Minnesota [6]. Risk

factors associated with NCCP include elevated BMI, family

history of gastroesophageal reflux disease (GERD), previous

cigarette use, and aspirin use. However, one-third of the pa-

tients identified in this study of risk factors had unexplained

chest pain, inconsistent with GERD or another specific cause

of chest pain [7]. This implicates multiple causal mechanisms

of NCCP.

The most common etiologies of NCCP are gastrointestinal,

respiratory, musculoskeletal, and psychogenic disorders [4].

Neurologic conditions, although not classically associated

with chest pain, may also be implicated in NCCP, as described

in several studies. This article will briefly discuss well-

recognized causes of chest pain followed by a focused review

of neurologic chest pain.

Cardiac Chest Pain

Cardiovascular disorders are classically associated with chest

pain and include many diagnoses, such as ACS, pericarditis,

and valvular disease. These present with a variety of symp-

toms. In ischemic heart disease, the characteristic feature is

pressure-like chest pain that may radiate to the left arm as well

as the back or jaw. It typically lasts several minutes, may be

associated with exertion, and is accompanied by nausea or

This article is part of the Topical Collection on Secondary Headache

*Matthew S. Robbins

mar9391@med.cornell.edu

Albert Einstein College of Medicine, Bronx, NY, USA

Department of Neurology, Weill Cornell Medicine, 520 East 70th

Street, Starr Pavilion 607, New York, NY 10021, USA

https://doi.org/10.1007/s11916-021-00944-5

/ Published online: 24 March 2021

Current Pain and Headache Reports (2021) 25: 32

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

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Herpes zoster, or shingles, is caused by reactivation of varicella zoster virus, which causes chickenpox. There are an estimated 1 million cases in the Unites States annually, with an individual lifetime risk of 30%. Patients with conditions that decrease cell-mediated immunity are 20 to 100 times more likely to develop herpes zoster. Patients may present with malaise, headache, low-grade fever, and abnormal skin sensations for two to three days before the classic maculopapular rash appears. The rash is usually unilateral, confined to a single dermatome, and typically progresses to clear vesicles that become cloudy and crust over in seven to 10 days. Herpes zoster can be treated with acyclovir, valacyclovir, or famciclovir, ideally within 72 hours of the development of the rash. Postherpetic neuralgia is the most common complication, occurring in about one in five patients. It is defined as pain in a dermatomal distribution sustained for at least 90 days after acute herpes zoster. Treatment is focused on symptom control and includes topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants. The varicella zoster virus vaccine decreases the incidence of herpes zoster and is approved for adults 50 years and older. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends this vaccine for adults 60 years and older, except for certain immunosuppressed patients.

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