Headache at Onset of Acute Cerebral Ischemia

2021

Background: Defining the relationship between a headache and stroke is essential. The current diagnostic criteria of the ICHD-3 for acute headache attributed to ischemic stroke are based primarily on the opinion of experts rather than on published clinical evidence based on extensive case-control studies in patients with first-ever stroke. Diagnostic criteria for sentinel headache before ischemic stroke do not exist. The present study aimed to develop explicit diagnostic criteria for headache attributed to ischemic stroke and for sentinel headache.Methods: This prospective case-control study included 550 patients (mean age 63,1, 54% males) with first-ever ischemic stroke and 192 control patients (mean age 58.7, 36% males) admitted to the emergency room without any acute neurological deficits or severe disorders. Standardized semi-structured interview forms were used to evaluate past and present headaches during face-to-face interviews by a neurologist on admission to the emergency r...

The Journal of Headache and Pain, 2018

Background: Headache is a common feature in acute cerebrovascular disease but no studies have evaluated the prevalence of specific headache types in patients with transient ischemic attacks (TIA). The purpose of the present study was to analyze all headaches within the last year and the last week before TIA and at the time of TIA. Methods: Eligible patients with TIA (n = 120, mean age 56.1, females 55%) had focal brain or retinal ischemia with resolution of symptoms within 24 h without presence of new infarction on MRI with DWI (n = 112) or CT (n = 8). All patients were evaluated within one day of admission by a single neurologist. As a control group we used patients (n = 192, mean age 58.7, females 64%) admitted with diagnoses "lumbago", "lumbar spine osteochondrosis" or "gastrointestinal ulcer". Results: One-year prevalence of migraine without aura was significantly higher in TIA patients than in controls: 20.8% and 7.8% respectively (p = 0.002, OR 3.1, 95% CI 1.6-6.2). 22 patients (18.3%) had sentinel or warning headache within the last week before TIA. At the time of TIA a new type of headache was observed in 16 patients (13.3%). No controls had a new type of headache. 12 of these 16 patients had migraine-like headache, 8 patients had tension-type-like headache and one patient thunderclap headache. Posterior circulation TIA was associated with headaches within last week before TIA and at the time of TIA much more frequently than anterior circulation TIA. Conclusions: The one year prevalence of migraine was significantly higher in TIA patients than in controls and so was the prevalence of headache within the last week before TIA and at the time of TIA. A previous headache that worsens and a new type of headache can be a warning of impending TIA.

Journal of Headache and Pain, 2022

Background: It is poorly described how often headache attributed to stroke continues for more than 3 months, i.e. fulfils the criteria for persistent headache attributed to ischemic stroke. Our aims were: 1) to determine the incidence of persistent headache attributed to past first-ever ischemic stroke (International headache society categories 6.1.1.2); 2) to describe their characteristics and acute treatment; 3) to analyse the prevalence of medication overuse headache in patients with persistent headache after stroke; 4) to evaluate factors associated with the development of persistent headache after stroke. Methods: The study population consisted of 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke, among them 529 patients were followed up at least three months after stroke. Standardized semi-structured interview forms were used to evaluate these headaches during professional face-to-face interviews at stroke onset and telephone interviews at 3 months. Results: At three months, 61 patients (30 women and 31 men, the mean age 60.0) of 529 (11.5%) follow-up patients had a headache after stroke: 34 had a new type of headache, 21 had a headache with altered characteristics and 6 patients had a headache without any changes. Therefore 55 (10.4%) patients had a persistent headache attributed to ischemic stroke. Their clinical features included: less severity of accompanying symptoms, slowly decreasing frequency and development of medication overuse headache in one-third of the patients. The following factors were associated with these headaches: lack of sleep (29.1%, p = 0.009; OR 2.3; 95% CI 1.2-4.3), infarct in cerebellum (18.2%, p = 0.003; OR 3.0; 95% CI 1.4-6.6), stroke of undetermined etiology (50.9%, p = 0.003; OR 2.3; 95% CI 1.3-4.1), less than 8 points by NIHSS score (90.9%, p = 0.007; OR 3.4; 95% CI 1.4-8.6) and low prevalence of large-artery atherosclerosis (12.7%, p = 0.006; OR 0.3; 95% CI 0.2-0.80). Conclusion: Persistent headache attributed to ischemic stroke is not rare and frequently leads to medication overuse. The problem is often neglected because of other serious consequences of stroke but actually, it has a considerable impact on quality of life. It should be a focus of interest in the follow-up of stroke patients.

Cephalalgia, 2006

Headache is a frequent accompaniment of acute ischaemic stroke. The predisposing factors and underlying mechanisms are currently incompletely defined. We analysed prospectively collected data relevant to headache occurring at ischaemic stroke onset in consecutive patients included in the Henry Ford Hospital Stroke Data Bank. Patients with headache (HA+) and without headache (HA–) were compared for demographic factors, medical history, medications, examination findings, laboratory findings, and stroke localization and subtype. Group comparisons for categorical data were performed with χ2 test, and for continuous variables with two-sample t-tests. Stepwise logistic regression analysis, including all variables with P < 0.25, was used to define the independent predictors of onset headache. Three hundred and seventy-five patients had complete headache and clinical datasets and were included in the analysis (HA+, N = 118; HA–, N = 257). Multivariate analysis revealed that the independe...

Journal of Headache and Pain, 2020

Background: There are no previous controlled studies of sentinel headache in ischemic stroke. The purpose of the present study was to evaluate the presence of such headache, its characteristics and possible risk factors as compared to a simultaneous control group. Methods: Eligible patients (n = 550) had first-ever acute ischemic stroke with presence of new infarction on magnetic resonance imaging with diffusion-weighted imaging (n = 469) or on computed tomography (n = 81). As a control group we studied in parallel patients (n = 192) who were admitted to the emergency room without acute neurological deficits or serious neurological or somatic disorders. Consecutive patients with stroke and a simultaneous control group were extensively interviewed soon after admission using validated neurologist conducted semi-structured interview forms. Based on our previous study of sentinel headache in transient ischemic attacks we defined sentinel headache as a new type of headache or a previous kind of headache with altered characteristics (severe intensity, increased frequency, absence of effect of drugs) within seven days before stroke. Results: Among 550 patients with stroke 94 patients (17.1%) had headache during seven days before stroke and 12 (6.2%) controls (p < 0.001; OR 3.9; 95% CI 1.7-5.8). Totally 81 patients (14.7%) had sentinel headache within the last week before stroke and one control. Attacks of arrythmia during seven days before stroke were significantly associated with sentinel headache (p = 0.04, OR 2.3; 95% CI 1.1-4.8). Conclusions: A new type of headache and a previous kind of headache with altered characteristics during one week before stroke are significantly more prevalent than in controls. These headaches represent sentinel headaches. Sudden onset of such headaches should alarm about stroke.

Stroke, 1984

Two hundred fifteen consecutive patients with cerebrovascular events were evaluated prospectively for the incidence and characteristics of headache. Of 163 patients able to communicate, headache occurred in 29% with bland infarcts, 57% with parenchymal hemorrhage, 36% with transient ischemic attacks and 17% with lacunar infarcts. Patients with a history of recurrent throbbing headache were significantly more likely to have headache, usually throbbing in quality, during the present illness. Women developed headache significantly more often than men. Headache began prior to the vascular event in 60% of patients and at its onset in 25%. The quality, onset and duration of the headache varied widely among patients. Headache in cerebrovascular disease is common, though neither its occurrence nor characteristics predict lesion type or location. Though the pathogenesis of the headache is unknown, its association with prior throbbing headache suggests that similar factors may operate in both.

Neurology, 2016

To investigate the role of large vessel atherosclerosis, blood clot extent, and penumbra volume in relation to headache in ischemic stroke patients. In this cross-sectional study, we performed noncontrast CT, CT angiography (CTA), and CT perfusion (CTP) in 284 participants from the Dutch Acute Stroke Study and Leiden Stroke Cohort within 9 hours after ischemic stroke onset. We collected headache characteristics prospectively using a semi-structured questionnaire. Atherosclerosis was assessed by evaluating presence of plaques in extracranial and intracranial vessels and by quantifying intracranial carotid artery calcifications. Clot extent was estimated by the clot burden score on CTA and penumbra volume by CTP. We calculated risk ratios (RRs) with adjustments (aRR) for possible confounders using multivariable Poisson regression. Headache during stroke was reported in 109/284 (38%) participants. Headache was less prevalent in patients with than in patients without atherosclerosis in ...

Journal of Neurology, Neurosurgery & Psychiatry, 1995

Within 12 hours of stroke onset 2506 patients with first ever stroke admitted to the Lausanne Stroke Registry were questioned about headache. Eighteen per cent of the patients reported headache, 14% with anterior circulation stroke and 29% with posterior circulation stroke (p < 0.001). Headache was reported by 16% of the patients with infarct and 36% of those with haemorrhage (p < 0.001).

Folia Neuropathologica

Despite high prevalence of cerebrovascular stroke, headache attributed to ischemic strokes is often undertreated and overlooked. The aim is to detect the relation of a post-stroke headache to cerebrovascular pathology and changes in hemodynamics through a high-resolution duplex ultrasound examination. The present study was a case-control study conducted among 239 patients, who presented with an acute ischemic stroke. Patients were subdivided into two groups: group I included patients with headache attributed to ischemic stroke (cases) and group II included headache-free stroke patients (controls). History consisted of headache characteristics and risk factors. Clinical and radiological examination were preformed to detect the type of stroke. Ultrasound duplex examination of extra-cranial and intra-cranial cerebrovascular system was carried for both groups. Group I included 112 patients (mean age, 57.66 ±6.59 years), and group II included 127 patients (mean age 57.73 ±7.89 years). Post-stroke headache was more frequent in patients with posterior circulation infarction (58%). Post-stroke headache was reported within 7 days post-stroke in 61.6% of patients. Pre-stroke headache was an independent predictor for post-stroke headache occurrence (OR = 28.187, 95% CI: 6.612-120.158%, p < 0.001). Collateral opening and various degrees of intra-cranial vascular stenosis were strong predictors of headache occurrence (OR = 25.071, 95% CI: 6.498-96.722%, p < 0.001). In conclusion, post-stroke headache is a common phenomenon, especially in patients with pre-stroke headache, history of old stroke, posterior circulation infarction, and large artery disease. This headache was of moderate-intensity with clinical characteristics of tension-type. Intra-cranial cerebrovascular pathological changes including opening of collateral channels and variable degrees of stenosis of cerebrovascular systems were implicated in the production of that headache.

Stroke, 2013

Background and Purpose— The study aimed to assess whether onset headache is an ominous sign in patients with first-ever ischemic stroke. Methods— A large population of ischemic stroke patients was obtained from the Taiwan Stroke Registry. Stroke subtypes were classified by the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. On the basis of the International Classification of Headache Disorders, second version, onset headache was defined as a new headache that developed at the onset of ischemic stroke. Clinical features and impact on stroke outcomes, including in-hospital stroke in evolution, changes in National Institutes of Health Stroke Scale on discharge, and Barthel index and modified Rankin scale ≤6 months after stroke were compared between those with and without onset headache. Results— Among 11 523 patients with first-ever ischemic stroke, 848 had onset headache (7.4%). Patients with specific cause, large-artery atherosclerosis, or cardioembolism were more like...

Brain, 2015

Headache is a common symptom in acute ischaemic stroke, but the underlying mechanisms are incompletely understood. The aim of this lesion mapping study was to identify brain regions, which are related to the development of headache in acute ischaemic stroke. Patients with acute ischaemic stroke (n = 100) were assessed by brain MRI at 3 T including diffusion weighted imaging. We included 50 patients with stroke and headache as well as 50 patients with stroke but no headache symptoms. Infarcts were manually outlined and images were transformed into standard stereotaxic space using non-linear warping. Voxel-wise overlap and subtraction analyses of lesions as well as non-parametric statistics were conducted. The same analyses were carried out by flipping of left-sided lesions, so that all strokes were transformed to the same hemisphere. Between the headache group as well as the nonheadache there was no difference in infarct volumes, in the distribution of affected vascular beds or in the clinical severity of strokes. The headache phenotype was tension-type like in most cases. Subtraction analysis revealed that in headache sufferers infarctions were more often distributed in two well-known areas of the central pain matrix: the insula and the somatosensory cortex. This result was confirmed in the flipped analysis and by non-parametric statistical testing (whole brain corrected P-value 5 0.01). To the best of our knowledge, this is the first lesion mapping study investigating potential lesional patterns associated with headache in acute ischaemic stroke. Insular strokes turned out to be strongly associated with headache. As the insular cortex is a well-established region in pain processing, our results suggest that, at least in a subgroup of patients, acute stroke-related headache might be centrally driven.

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, 2003

ABSTRACT:Background:Elevation of blood pressure (BP) is common in acute cerebral infarction, with several studies reporting a high plasma catecholamine level or previous hypertension as a contributory factor. However, more comprehensive studies on associated clinical parameters are lacking. Our main aim in undertaking this study was to correlate clinical variables associated with a BPelevation in acute ischemic stroke.Methods:Consecutive patients who were admitted to the emergency room and diagnosed with an acute cerebral infarction within 24 hours after the onset of symptoms were investigated. A BP elevation was defined as a high systolic (³200mmHg) or diastolic (³110 mmHg) pressure. The mean systolic and diastolic BP were compared between the different stroke subtypes, lesion locations (carotid vs. vertebrobasilar), and hemispheric sides. The frequency of symptoms, risk factors, location of the infarct, stroke severity, vascular status and laboratory abnormalities were analyzed in...

Cephalalgia, 2014

Background: Headache following stroke has been described in previous studies with an incidence of 23%-54%, but a clear description of headache developing after stroke onset is still lacking. The aim of this study was to determine the incidence and characteristics of persistent novel headache after stroke and to describe the use of medication, including dipyridamole. Methods: As a follow-up to a prospective study, a standardized questionnaire about characteristics of novel headache and medication use was sent out to surviving patients three years after their stroke. Results: The questionnaire was sent to 256 patients and returned by 222, of whom 12% (26/222) of patients reported persistent novel headache. Dipyridamole had no significant influence on the incidence. Stroke-attributed headache according to predefined criteria was reported in 7.2% (16/222) of patients, with tension-type-like headache in 50.0%, migraine-like in 31.3% and medication overuse in 6.25% of patients. More than half of patients experienced moderate to severe pain and had a score of 55 or above on the Headache Impact Test-6 scale. Conclusion: Novel headache after stroke affects one in 10 patients and seems to be unrelated to dipyridamole use. Persistent headache attributed to stroke is similar to tension-type headache for half of patients.

Headache: The Journal of Head and Face Pain, 2005

Objective.-To describe the characteristics of headache related to lacunar stroke based on data collected from a prospective hospital-based stroke registry over a 12-year period. Demographics, clinical variables, and prognostic features of lacunar stroke in patients with and without headache are compared. Background.-Stroke-related headache has been largely investigated, but there is little clinical data on headache in individualized stroke subtypes. Methods.-The cohort of 484 patients with lacunar infarction was selected. Forty-five (9.3%) presented headache within a 72-hour interval of stroke onset. Predictors of lacunar infarction with headache were assessed by logistic regression analysis. Results.-The intensity of headache was mild in severity and poorly localized (diffuse or bilateral headache). Tension-type headache was present in 36 patients (80%) and 9 patients (20%) presented nausea or vomiting while experiencing mild pulsating pain. The frequency of headache was 17% in patients with atypical lacunar syndrome, 12% in dysarthria-clumsy hand, 11.5% in pure sensory stroke, 9.4% in sensorimotor stroke, and 7.1% in pure motor hemiparesis. When patients with lacunar infarction with and without headache were compared, female sex, diabetes mellitus, nausea and vomiting, and mesencephalic topography were significantly more frequent and dysarthria and frequency of symptom free at discharge were less frequent in the headache group. In the multivariate analysis, mesencephalic topography (odds ratio [OR] 16.62), nausea and vomiting (OR 13.27), sex female (OR 2.29), diabetes mellitus (OR 1.96), and age (OR 0.95) were predictors of lacunar infarction with headache. Conclusions.-Headache at the onset of a lacunar infarction is uncommon. Mesencephalic topography, nausea and vomiting, female sex, diabetes, and age were independent variables significantly associated with lacunar infarction with headache. These findings contribute to knowledge of stroke-related headache in patients with lacunes.