Sentinel headache as a warning symptom of ischemic stroke

Abstract

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.

Headache Characteristics in the Neurological Emergency Department: A Retrospective Study

“…A meta-analysis by Harriott et al found a pooled prevalence of 14%, with an increased risk of headache in the case of cerebral ischemia in the posterior circulation and for the female sex ( 27 ). An analysis of an Israeli stroke register over 2 months including 2,166 patients revealed that 8.4% had suffered from headache and cerebral ischemia, and a large proportion of 28% of patients suffered from TIA and headache ( 28 , 29 ).…”

“…A meta-analysis by Harriott et al found a pooled prevalence of 14%, with an increased risk of headache in the case of cerebral ischemia in the posterior circulation and for the female sex (27). An analysis of an Israeli stroke register over 2 months including 2,166 patients revealed that 8.4% had suffered from headache and cerebral ischemia, and a large proportion of 28% of patients suffered from TIA and headache (28,29). Detailed phenotypic data were documented in only 42% of patients, which is surprisingly low given that this information is essential for classifying the headache according to the current headache classification.…”

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

“…All headaches were diagnosed according to the International Classi cation of Headache Disorders 3rd edition (ICHD-3) [ 5]. We de ned 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) which arose within seven days before stroke [3].…”

“…The ICHD-3 does not include diagnostic criteria for sentinel headache before an ischemic stroke. Our previous study [3] characterized sentinel headache before ischemic stroke in 550 patients with rst-ever ischemic stroke, we propose explicit diagnostic criteria for sentinel headache. Totally 94 patients had headaches within the last week before a stroke and 12 in the control group.…”

“…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.…”