Headache at onset of first‐ever ischemic stroke: Clinical characteristics and predictors

Abstract

No studies have prospectively investigated headache at onset of first‐ever ischemic stroke along with a large concurrent control group. Our aims were to answer two important questions: (i) Are headaches at stroke onset causally related to the stroke, and what are their typical clinical characteristics? (ii) What etiology of stroke is associated with these headaches? The study population consisted of 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 serious disorders. All data were collected prospectively, using a standardized case‐report form during face‐to‐face interviews by neurologists. Headache at onset of ischemic stroke was present in 82 (14.9%) of 550 patients. More than half (56%) had a new type of headache (mainly migraine‐like) simultaneously with stroke onset, and 36% had headache with altered characteristics (mainly tension‐type‐like headache). Headaches were associated with cardioembolism (p = 0.002, odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.4–4.1), posterior circulation stroke (p = 0.01, OR = 2.0, 95% CI = 1.2–3.5), infarcts >15 mm (p = 0.03, 95% CI = 1.1–2.7), infarcts of the cerebellum (p = 0.02, OR = 2.3, 95% CI = 1.1–4.8), good neurological status (p = 0.01, OR = 2.5, 95% CI = 1.2–4.9), and low frequency of large‐artery atherosclerosis (p = 0.004, OR = 0.4, 95% CI = 0.2–0.8). At stroke onset, headache of a new type and headache with altered characteristics were related to ischemic stroke. They were associated with certain etiologies of stroke.

Diagnostic Criteria For Acute Headache Attributed To Ischemic Stroke And For Sentinel Headache Before Ischemic Stroke.

“…According to our previous studies, 18.3% of the patients with TIA had sentinel headache within the last week before TIA [9], and 14.7% had sentinel headache before ischemic stroke [4]. We found that attacks of arrhythmia before a stroke and a history of atrial brillation were associated with this headache in stroke patients [4]. These data suggest that emboli can play an essential role in the development of this headache [4].…”

“…We found that attacks of arrhythmia before a stroke and a history of atrial brillation were associated with this headache in stroke patients [4]. These data suggest that emboli can play an essential role in the development of this headache [4]. However, sentinel headache may be an alarming symptom in many other disorders (dissections, cerebral venous sinus thrombosis, etc.).…”

“…Since we studied symptoms before a rupture of intracranial aneurysms and observed such headaches [8], we decided to assess the presence of sentinel headache before ischemic stroke and transient ischemic attacks (TIA) [4,9]. According to our previous studies, 18.3% of the patients with TIA had sentinel headache within the last week before TIA [9], and 14.7% had sentinel headache before ischemic stroke [4]. We found that attacks of arrhythmia before a stroke and a history of atrial brillation were associated with this headache in stroke patients [4].…”

“…Headaches at the time of stroke were de ned as within 24 hours after stroke onset [4]. A new type of headache was de ned as a headache that arose for the rst time after the onset of stroke or before the stroke.…”

“…Headaches that happen in the stroke group and not in the control group must be caused by the stroke. We studied sentinel headache before ischemic stroke and also headache at onset of rst-ever ischemic stroke [3,4]. However, the current diagnostic criteria 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 of these headaches in patients with rst-ever ischemic stroke.…”