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


During the study period, 102 patients were considered eligible for the study (flowchart in supplementary material). Eighty-nine patients (87.3%) (81 personal in site interviews and 8 phone contacts) completed the follow-up evaluation. Average follow-up time was 15.6 months (median 14 months IQR 12–16). Seven patients died before the 12 months of follow-up so we were not able to describe their headache at chronic stage. Patients who died had nonstatistically significant differences compared to those who completed follow-up (data not shown, detailed frequencies can be given if requested). Six patients were lost to follow-up. Patients lost to follow-up had nonstatistically significant differences concerning sex, age, stroke severity, stroke location, and pre-stroke history of headache comparing to those who completed follow-up (data not shown, detailed frequencies can be given if requested).

Main characteristics of the included sample at the acute stage and of the sample evaluated at the chronic stage are presented in Table 1 accordingly to the presence and absence of headache. There were no differences considering subtype of stroke (Table S2 of the supplementary material).

Headache Characteristics at the Chronic Stage of Ischemic Stroke

At the chronic stage 45/89 (51%) patients reported headache. In most of the patients the headache was sporadic (n = 21/43). Most of the patients described headache intensity as mild (n = 28/41) and only 6 (7%) patients reported severe headache. Most of the patients reported headache duration of hours (n = 17/41) or minutes (n = 17/41). Pressure was the most frequently described quality (n = 28/42) of pain, followed by stabbing type (n = 8/42). Headache was unilateral in half of the patients (n = 21/42) and more frequently located in the anterior region (n = 24/42). Nine patients (20%) required sporadic short-term analgesic medication due to the headache.

Accordingly to the IHS criteria, tension-type headache was the most frequent (n = 23/45, 51%), followed by stabbing-type (n = 8/45, 18%) and migraine-type (n = 6/45, 13%). In 16 patients (18/45%) the headache-type was non-classifiable by the IHS criteria.

Headache Pre-stroke to Stroke

More than half of the patients had pre-stroke history of headache. Pre-stroke headache was sporadic in 47% (n = 25/53) of patients and frequent in 54% (n = 29/53) of patients. In 22% (n = 12/54) pre-stroke headache was severe. Migraine headache was referred by 53% (n = 30/56) (3 of them with aura) and tension headache by 41% (n = 23/56). Other types of headache were recorded by 2 patients (1 stabbing headache and 1 unclassified).

Headache at the Chronic Stage and Pre-stroke Headache

Within the patients who reported headache at the chronic stage, headache had similar characteristics of pre-stroke headache (reactivation of pre-stroke headache) in 33% (n = 15/45), was different from pre-stroke headache in 44% (n = 20/45) and was an headache of new-onset in 22% (n = 10/45). Within the subgroup of patients with a reactivation of the pre-stroke headache, 9 of them (60%) had history of tension-type headache and 6 had history of migraine-type headache (40%). Comparing pre-stroke headache with headache at the chronic stage in the patients with reactivation of pre-stroke headache, the intensity of the pain did not change in 73% (n = 11/15). Regarding the subgroup of patients who described headache at the chronic stage with different characteristics from the pre-stroke headache, 15 of them (75%) had migraine-type headache in the past that changed most frequently to tension-type (35%) at the chronic stage. Of the patients with headache of new-onset 7 of them (70%) reported tension-type headache. Sixteen (18%) patients stopped complaining of headache which was present before the stroke. The details of pre-stroke headache and headache at chronic stage are specified on Table S3 of the supplementary material.

Headache at the Chronic Stage and Headache at the Acute Stage

Thirty-one patients (35%) who presented headache at the chronic stage had reported headache during the acute stage of stroke. Characteristics of headache at acute stage is presented in supplementary material (Table S1 of supplementary material). In most of these patients (n = 25/31, 81%) headache characteristics were different between acute and chronic stage, changing from migraine-type to tension-type in most of them (n = 18, 58%). Only 1 patient (1%) had headache of new-onset at the acute stage that persisted with the same characteristics at the chronic stage.

Headache Predictors at the Chronic Stage After Stroke

Using logistic regression analysis, headache at the chronic stage was predicted by headache previous to stroke (OR = 5.3; β = 1.7; 95% CI [2.01–13.98] P = .001) and female sex (OR = 3.5; β = 1.3; 95% CI [1.3–9.4] P = .013) (Nagelkerke R 2 0.299; P < .001), controlling for age, severity of stroke, and location of stroke. The specificity of the model was 73.7%, the sensitivity was 68.6%, positive predictive value was 27.8%, and negative predictive value was 63.6%. Results were similar when controlling for functional status at chronic stage and depressive symptoms at the chronic stage. The 2 predictors were not correlated. Headache at the chronic stage after stroke was more frequent in patients with headache associated with acute stroke (Table 1), but the inclusion of headache in acute stroke in the regression model did not change the results in the final model (results can be shown if requested).