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


We found that headache at the chronic stage of ischemic stroke is frequent, occurring in about half of stroke survivors. Pain was usually sporadic, of mild intensity, of pressure-type, and lasting minutes to hours. Using IHS classification, headache at the chronic stage after stroke could be classified most frequently as tension-type headache.[16]

The most significant finding of our study was that stroke appears to have a modulating effect on the headache in most stroke survivors. Almost half of stroke survivors complaining of changes to their headache type, most frequently from migraine-type to tension-type, roughly one-third complained of pre-stroke headache, and less than a quarter start complaining of headache with a delayed onset only after stroke. Our findings are particularly relevant because, until now, the only reference to headache in ischemic stroke survivors on ICHD classification was persistent headache attributed to past ischemic stroke defined as an headache that starts during acute stage and persists after stroke, which represented only 1% of our sample.

The main limitation of our study is the small sample size and the fact that most of patients included had nonsevere strokes, because several patients could not be included due to inability to cooperate in the headache questionnaire. These exclusion criteria limit the generalization of the results. In our study, 10% of subjects were unable to attend follow-up visits (because of death or lost for follow-up), but it is unlikely that those subjects could have changed results because their characteristics were similar to those who were interviewed.

The strengths of our study are the prospective collection data, with face-to-face interviews to stroke survivors using a validated questionnaire to classify headache according to the IHS criteria, and consideration of potential confounders. Most of the available information regarding headache in the chronic stage of ischemic stroke comes from post-stroke pain studies[11–15] with several limitations. None of those studies was addressed specifically to study ischemic stroke population and included patients with hemorrhagic strokes and other cerebrovascular diseases. Those studies included all types of pain after stroke and did not use a validated headache questionnaire enabling the classification of headache following the ICHD classification. With the exception of one study,[11,12] in which the 3 and 6 month-follow-up was made by phone interview, in all the other studies the follow-up was made using a postal survey with a high non-responder rate.

The reported prevalence of headache at chronic stage (from 3 months to 3 years) of ischemic stroke on previous studies is 7%-23%.[10–14] We found a higher frequency of headache at the chronic stage than previously described probably because of the prospective nature of the study and the fact that we focused specifically in headache and not to other types of pain or symptoms after stroke. We found 11% of new-onset headache at the chronic stage, similar to the previously described.[11] Improvement and even remission of pre-existing headache disorders in up to 9.4% of patients after stroke were also previously reported.[2]

In our study headache in the chronic stage after stroke was predicted by previous history of headache and by female sex, as reported by others, but we did not confirm other predictors as severity of stroke and location of the lesion.[10–15] It is possible that severity and location of the lesion are more associated with headache in hemorrhagic strokes.[9] Although headache in the chronic stage was more frequent in patients with headache at the acute stage, the later was not a predictor for headache at the chronic stage.

The findings of this longitudinal study, using a validated tool for the classification of headache, may be useful in a future update of ICHD to more explicitly define the diagnostic features of "persistent post-stroke headache" but also of other headache patterns in the chronic stage of stroke.