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Senthil Raghunathan MD, MRCP, Bella Richard MSc, FRCP, Pradeep Khanna MBE, FRCP
S
Stroke is the third most common cause of death and • Thrombotic than embolic ischaemic events
the single most common cause of severe disability in • Cortical than deep white matter infarcts
developed countries. Headache is a relatively common • Venous than arterial infarction.
symptom associated with cerebrovascular disease, Table 1 shows the prevalence of headache in dif-
with a prevalence varying between 24 and 54 per cent1 ferent types of stroke1 and Table 2 shows the preva-
depending on the type and location of the cerebrovas- lence of headache in ischaemic stroke according to
cular event. Headache is well known to be associated the artery involved in the infarct.7
with various types of stroke, including intracranial
haemorrhage, subarachnoid haemorrhage, giant cell Aetiology
arteritis, carotid or vertebral arterial dissection, migra- Several hypotheses exist regarding the cause of
nous strokes, meningitis and intracranial venous sinus headaches in stroke but the exact aetiology remains
thrombosis.2 unclear. Most studies confirm that stroke in the pos-
Headache is a frequently overlooked symptom in terior cerebral circulation is more often associated
ischaemic stroke and studies investigating its char- with headache. One possible reason could be the
acteristics and clinical implications are limited. This presence of heavily inner vated pain sensitive ves-
review article focuses on headache in various types sels at the base of the brain,8 leading to activation
of ischaemic stroke, its epidemiology, aetiology, asso- of nociceptive trigeminovascular afferents resulting
ciated clinical factors and characteristics. in headache.
Another hypothesis is that the pain is caused by
Headache in various types of stroke vasodilatation of arteries9 following emboli/thrombus
The incidence of headache in ischaemic stroke is esti- formation at the base of the brain or occlusion of sev-
mated to vary from 25-29 per cent,3 from the limited, eral arterial branches, leading to changes in vascular
mostly retrospective studies carried out so far. This is perfusion. This mechanism could explain headaches
likely to be an underestimate, as a significant propor- in embolic or thrombotic strokes but does not explain
tion of patients in these studies could not respond due its occurrence in TIA.
to aphasia or altered mental status secondary to under- A further suggestion is that headache may be
lying stroke.1 caused by release of vasoactive substances, such as
Headache is more frequently associated with serotonin and prostaglandins, from activated platelets.10
haemorrhagic stroke (34-60 per cent) than ischaemic This hypothesis would certainly explain a lower inci-
stroke.4 Headache is also more commonly associated dence of headaches in patients with small deep lesions,
with transient ischaemic attacks (TIAs) than where platelet activation has not been demonstrated.
ischaemic stroke, with incidence rates of 25-44 per Headache in vertebrobasilar stroke is more often
cent5 reported in various studies. a migraine-type pain, which suggests that migraine
Ischaemic stroke in the basilar distribution area, and stroke share a common pathological neural mech-
especially the posterior cerebral circulation, is more anism in their underlying cause.8
often associated with headache than stroke in the
carotid distribution area.6 Association with clinical factors
Headache is more frequently associated with:1 Headache is a common symptom in acute stroke, but
• Haemorrhagic stroke than infarcts its association with clinical factors differs according
• Posterior than anterior circulation infarcts to various studies. The largest study to date, carried
www.progressnp.com Progress in Neurology and Psychiatry 21
Review
Headache in ischaemic stroke
Type of stroke Prevalence of stroke severity measured by the modified Rankin scale
at one week after the event. Vascular risk factors, such
headache
as hypertension and cigarette smoking, and also time
of the day, did not show a significant association with
Haemorrhagic stroke 23-60% headache at stroke onset.
Transient ischaemic attack 25-44%
Infarction: thrombotic 5-31% International Headache Society classification
Infarction: embolic 18-25% The International Headache Society (IHS) classifies
Lacunar infarct 4-11% headache associated with ischaemic cerebrovascular
disease as:12
Table 1. Prevalence of headache according to type of • IHS 6.1.1 – headache attributed to ischaemic stroke
cerebrovascular lesion9 (cerebral infarction); or
• IHS 6.1.2 – headache attributed to TIA.
the quality of pain in ischaemic cerebrovascular dis- patients. Further research is needed into the underly-
ease varies widely. The pain is most often non-specific ing aetiology and clinical significance of headache in
in character and has been reported as either throb- stroke and how it relates to other clinical factors.
bing or continuous and non-throbbing.1,8 It is rarely
felt as stabbing, pulsatile or having clinical features Dr Raghunathan is a Specialist Registrar, Dr Richard
similar to intracranial hypertension. It is frequently is an Associate Specialist and Dr Khanna is a
associated with nausea (44 per cent), vomiting (23 per Consultant Geriatrician and Lead Clinician in Stroke
cent), and photophobia and phonophobia. Care, all in the Department of Adult Medicine at
The headache is usually made worse by bending, Nevill Hall Hospital, Abergavenny
straining or jarring the head. Transient worsening can
also occur with the use of sublingual glycer yl trini-
trate. Digital compression of the superficial temporal References
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