Headache at the Chronic Stage of Ischemic Stroke

Mariana Carvalho Dias, MD; Teresa Martins, MD; Goncalo Basilio, MD; Lia Lucas Neto, MD, PhD; Lara Caeiro, Psy, PhD; Jose M. Ferro, MD, PhD; Ana Verdelho, MD, PhD


Headache. 2020;60(3):607-614. 

In This Article

Abstract and Introduction


Background: Headache in ischemic stroke survivors after the acute stage is incompletely described.

Objective: We aimed to prospectively describe the characteristics of headache and the predictors of headache at the chronic stage after ischemic stroke.

Methods: We conducted a prospective observational cohort study including 102 acute ischemic stroke patients admitted to a Stroke Unit. Patients were interviewed at the acute and the chronic stage (12 months after stroke). Characteristics of those headaches were collected using a previously validated headache questionnaire enabling headache classification following the International Headache Society criteria. Pre-stroke headache history was registered using the same instrument.

Results: Forty-five patients out of 89 with completed follow-up (51%) reported headache at the chronic stage. In most of the patients, headache was sporadic, mild, pressure-like, with a duration of minutes to hours, with characteristics of tension-type headache in 51% (n = 23/45). Headache was a reactivation of pre-stroke headache in 33% (n = 15/45), different from pre-stroke headache in 44% (n = 20/45), and of new-onset in 22% (n = 10/45). Only 1 patient had a new-onset headache at the acute stage that persisted with the same characteristics at the chronic stage.

Pre-stroke headache (OR = 5.3; 95% CI [2.01–13.98] P = .001) and female sex (OR = 3.5; 95% CI [1.3–9.4] P = .013) predicted headache at the chronic stage after stroke, controlling for age, severity, and location of stroke.

Conclusions: Headache in ischemic stroke survivors at the chronic stage is more frequent in women and in patients with pre-stroke headache. It is most frequently a headache with different characteristics of the pre-stroke headache and only rarely a new-onset headache starting at the acute stage and persisting at the chronic stage.


Headache is a common complaint of stroke survivors and it is better characterized in the acute stage.[1–8] Headache in intracerebral hemorrhage survivors was reported as frequent and mostly as a tension-type or migraine-type headache.[9] Headache in ischemic stroke survivors after the acute stage is incompletely described. A recent review[10] emphasized the need to a better knowledge of the natural history of headache in the chronic stage after stroke. Previous studies[10–15] included any kind of pain, usually did not distinguish between stroke types and, with the exception of one study,[11] did not use uniform tools for the description of headache in the chronic stage after stroke. The only prospective study that investigated this topic[11] was a study designed for the study of pain of any type after stroke. In this study, headache characteristics at the chronic stage were evaluated by mail questionnaires. The 2018 International Classification of Headache Disorders, 3rd edition (ICHD-3) has recently included a category of "persistent headache attributed to past ischemic stroke" as a headache caused by ischemic stroke and persisting for more than 3 months after stroke stabilization.[16]

In the current study, we followed-up a cohort of stroke survivors, admitted to a stroke Unit, aiming to describe the characteristics of headache at the chronic stage after ischemic stroke, and its predictors.