Post-stroke headache: a review of epidemiology, pathophysiology, and clinical management

 Your competent? doctor implemented this aneurysm identification a long time ago, right! Oh NO! Your doctor is incompetent; what are YOU going to do about that? 

Do you prefer your doctor, hospital and board of director's incompetence NOT KNOWING? OR NOT DOING? Your choice; let them be incompetent or demand action!

New Tool Identifies Patients With Headache Who Are at Risk of Aneurysms November 2017 

The latest here:

Post-stroke headache: a review of epidemiology, pathophysiology, and clinical management

• D

  Dabao Yao

• L

  Luwei Nie

• 

  Danyang Chen

• S

  Shiling Chen

• X

  Xuan Wu

• 

  Chao Pan

• Y

  Yingxin Tang

• 

  Na Liu *

• 

  Zhouping Tang *

• Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China

Abstract

Post-stroke headache (PSH) and its chronic counterpart, persistent post-stroke headache (PPSH), represent significant but frequently overlooked complications of cerebrovascular disease that adversely affect rehabilitation and quality of life. This review provides an updated synthesis of PSH, following its formal classification in the International Classification of Headache Disorders, 3rd edition (ICHD-3). We examine the epidemiology of PSH, noting a prevalence range of 6–44% in ischemic stroke survivors, with risk factors including younger age, female sex, and posterior circulation lesions. The pathophysiology is explored as a complex interplay involving the trigeminovascular system, neurogenic inflammation, and central sensitization, often exacerbated by structural factors such as edema and stroke topography. Clinical phenotypes vary, predominantly presenting as tension-type, though migraine-like features occur. Furthermore, this review highlights the critical role of headache as a sentinel symptom in the differential diagnosis of distinct stroke etiologies such as cervical artery dissection, reversible cerebral vasoconstriction syndrome, and cerebral venous thrombosis. A major finding is the significant gap in evidence-based management; current therapeutic strategies often rely on extrapolating data from primary headache disorders, with unverified safety profiles for newer agents such as triptans and calcitonin gene-related peptide (CGRP) antagonists in the post-stroke population. We conclude by emphasizing the urgent need for randomized controlled trials to establish safe, effective pharmacological and non-pharmacological interventions for this disabling condition.

Nearly half of patients with hemorrhagic stroke experience headache

 So, you described something and incompetently provided NO EXACT NEXT STEPS TO SOLVE THE PROBLEM! In the business world that would be grounds for immediate firing. Aren't you glad you're in the absolutely incompetent stroke medical world?

Nearly half of patients with hemorrhagic stroke experience headache

Key takeaways:

• The systematic review included 24 studies and 4,688 adults with hemorrhagic stroke.
• There were no significant associations between headache and diabetes mellitus, hypertension, alcoholism or previous headache.

Nearly half of all patients with hemorrhagic stroke also experience headache across its acute and chronic phases that could contribute to long-term morbidity, according to a review published in Headache.

Yet the prevalence of headache varied substantially across populations and clinical settings, Bradley Ong, MD, adult neurology resident at Neurological Institute, Cleveland Clinic, and colleagues wrote.

Data derived from Ong B, et al. Headache. 2025; doi:10.1111/head.70008.

“In clinical practice, headaches after hemorrhagic stroke came up quite often in our clinical practice, but they were rarely addressed,” Ong told Healio.

Most treatment after stroke focuses on motor recovery and preventing its recurrence, he said, with headache treated as an incidental or transient symptom.

Bradley Ong

“When we looked at the literature, there was no clear, consolidated picture of how common these headaches are or how long they last,” Ong said. “That gap is what motivated this study.”

Ong and colleagues conducted a systematic review and meta-analysis that included 24 peer-reviewed, observational studies from Medline, Embase and CENTRAL with 4,688 adults (mean age, 56.9 years; weighted mean, 58.2% women) with hemorrhagic stroke.

“The most striking finding was how common headaches are,” Ong said. “Nearly half of patients with hemorrhagic stroke experience headache, and more than one-third go on to have persistent headaches months or years later.”

Overall, 46.1% (95% CI, 36.3% to 56.1%) of these patients experienced headache after their stroke. Eleven studies (n = 2,481) found that 55.9% of patients (95% CI, 41.1% to 70.1%) experienced acute headache. Thirteen studies (n = 2,207) found that 36.7% of patients (95% CI, 25.6% to 48.5%) had persistent headache.

“This challenges the assumption that headache is mainly an ‘acute’ symptom, especially in hemorrhagic stroke,” Ong said.

Specific prevalences of headache included 58.3% (95% CI, 44.4% to 71.6%) for those with subarachnoid hemorrhage (SAH) and 36.1% (95% CI, 26.7% to 46%) for those with intracerebral hemorrhage (ICH).

Prevalence of severe headaches included 42.7% (95% CI, 15.8% to 72.1%) among those whose headaches were acute/subacute and 14.3% (95% CI, 10.4% to 18.7%) among those whose headaches were persistent.

With an overall I2 of 96.7%, the researchers said their findings indicated substantial heterogeneity in these pooled prevalence estimates, with no statistically significant differences based on study design, population, geography, Human Developmental Index or risk for bias.

Further, Ong and colleagues said there were no significant associations between risk for headache and female sex, nor were there any significant associations with history of diabetes mellitus, hypertension, alcoholism or previous headache.

“Another important finding was that headache at stroke onset strongly predicted chronic headache, which gives us an early clinical signal we can actually act on,” Ong said.

The odds ratio for post-stroke headache among patients with headache at stroke onset was 1.7 (OR = 1.7; 95% CI, 1.4-2.05). Also, the odds ratio for post-stroke headache among patients with lobar ICH was 1.93 (95% CI, 1.08-3.44).

There were no significant associations between headache risk and cortical ICH or delayed cerebral ischemia. Also, there were no significant associations between headache risk and the presence of an anterior circulation aneurysm among patients with SAH.

Patients with atrial fibrillation had less risk for headache (OR = 0.59; 95% CI, 0.37-0.95), which the researchers attributed to differences in stroke severity and symptom reporting and not to any direct protective effect.

Noting that the prevalence of headache among patients with hemorrhagic stroke exceeds the prevalence of other primary headache disorders among the general population, with substantial variations by population and clinical settings, the researchers called these headaches “common” as well as “persistent and disabling.”

Ong said that clinicians can use these findings to improve outcomes for patients with stroke.

“Clinicians should ask about headache routinely, both in the hospital and during follow-up. Headache should be treated as a meaningful post-stroke complication,” he said.

“Patients who report headache early may benefit from closer monitoring and earlier referral to headache care,” he continued. “Even simple steps like education and avoiding unnecessary opioid exposure can improve quality of life.

Looking ahead, the researchers called for studies with standardized diagnostic criteria, clearly defined populations and detailed headache characteristics into protective therapies and secondary prevention strategies.

“The next step is prospective, longitudinal studies using standardized headache definitions and patient-reported outcomes,” Ong said.

“We also need clinical trials focused specifically on post-stroke headache treatment, rather than extrapolating from primary headache disorders,” he added. “Ultimately, the goal is to integrate headache care into routine stroke recovery.”

For more information:

Bradley Ong, MD, can be reached at ongb@ccf.org.

New Tool Identifies Patients With Headache Who Are at Risk of Aneurysms

Do you really think your stroke hospital is up-to-date enough to have this protocol in place? A great stroke association would make sure this is implemented in all stroke hospitals. 
http://dgnews.docguide.com/new-tool-identifies-patients-headache-who-are-risk-aneurysms?

OTTAWA, Ontario -- November 13, 2017 -- A new tool to identify potentially fatal aneurysms in patients with headaches who seem otherwise well will help emergency departments to identify high-risk patients, improve survival rates, and reduce unnecessary imaging, according to a study published in the Canadian Medical Association Journal (CMAJ).
“Although rare, accounting for only 1% to 3% of headaches, these brain aneurysms are deadly,” said Jeffrey Perry, MD, Ottawa Hospital, and the University of Ottawa, Ottawa, Ontario. “Almost half of all patients with this condition die and about 2/5 of survivors have permanent neurological deficits. Patients diagnosed when they are alert and with only a headache have much better outcomes, but can be challenging to diagnose as they often look relatively well.”
The Ottawa Subarachnoid Hemorrhage Rule was developed by researchers at the Ottawa Hospital, which also created The Ottawa Rules, decision tools used in emergency departments around the world to identify ankle, knee, and spine fractures.
The current study, involving 1,153 alert adult patients with acute sudden onset headache admitted to 6 university-affiliated hospitals in Canada over 4 years from January 2010 to 2014, validates earlier published research that initially proposed the Ottawa Subarachnoid Hemorrhage Rule.
“Before any clinical decision rule can be used safely, it must be validated in new patients to ensure that the derived ‘rule’ did not come to be by chance, and that it is truly safe,” said Dr. Perry. “This is especially true with a potentially life-threatening condition such as subarachnoid haemorrhage.”
The newly validated rule gives emergency physicians a reliable tool to identify high-risk patients and rule out the condition in low-risk patients without having to order time-consuming imaging.
“We hope this tool will be widely adopted in emergency departments to identify patients at high risk of aneurysm while cutting wait times and avoiding unnecessary testing for low-risk patients,” said Dr. Perry. “We estimate that this rule could save 25 lives in Ontario each year.”
Reference: http://www.cmaj.ca/site/press/cmaj.170072.pdf
SOURCE: Canadian Medical Association Journal

What Started as a Headache Was Actually a Stroke

Once again proving that we need a totally objective diagnosis of stroke. And I dislike the focus on the headache, headaches do not always precede stroke.
Maybe when we get actual objective diagnosis when these come online:
1. Star Trek-style 'tricorder' invention offered $10m prize
2. Strokefinder quickly differentiates bleeding strokes from clot-induced strokes
3.  One of these 17 ways still need to be be proven for fast and objective diagnosis.
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https://www.yahoo.com/health/it-started-as-a-headache-but-it-was-actually-a-93319686378.html

Too shaken up to drive, she called her husband, Bill, to come get her and take her back to their Gambrills, MD home. But when Bill arrived, he insisted they go to a hospital emergency room right away.

A CT scan revealed a spot on Amy’s brain, but the diagnosis was unclear. After recommending she see a neurologist in the next few weeks, the doctor released her.

Contact that hospital to see if they started researching objective diagnosis of strokes. Or are they waiting for someone else to actually do the work?  This was a complete failure on the part of the ER team. What are they doing to fix that problem?

Migraine With Aura May Be Linked to All Stroke Types

Check it out, but again correlation vs.causation needs your doctors experience.
http://health.usnews.com/health-news/news/articles/2013/06/26/migraine-with-aura-may-be-linked-to-all-stroke-types

A 2007 study here;

Is It Just a Headache? Study Links Migraine to Brain Damage in Mice

And how do the mice answer when asked if they have a migraine? I'd love to hear them describe an aura.

Migraine or stroke? Diagnostic test could provide answer

Could be quite useful, especially for those hypochrondriacs. You'll need classic stroke symptoms so your doctor can't mistake your obvious stroke; don't do the headache or vertigo ones: YOUR RESPONSIBILITY! 

Migraine or stroke? Diagnostic test could provide answer

Researchers from the University of Cincinnati are behind a startup that’s developing a medical device to help emergency doctors diagnose a severe type of headache that could be a warning sign for stroke.
Xanthostat Diagnostics’ device would analyze cerebral spinal fluid to determine if patients are suffering from sentinel subarachnoid hemorrhage (SAH), a painful headache that can signal a stroke. If undiagnosed — or even sometimes when they’re diagnosed — these major hemorrhagic strokes can lead to death.

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Each year, roughly 1 million patients show up in emergency rooms with symptoms such as severe headache, nausea and dizziness. Emergency doctors must then determine the patient’s medical issue from among the three most likely: severe headache, meningitis or SAH, according to the University of Cincinnati (UC).“While there are only about 30,000 cases of SAH in the U.S. annually, the significant chance for the catastrophic or even fatal outcome that can result from misdiagnosis of these million patients annually make this one of the most important diagnostic decisions faced by emergency room physicians,” said Fred Beyette Jr., a UC professor and member of the Xanthostat team.
Doctors typically perform a spinal tap to obtain cerebral spinal fluid that is then subjected to a chemical assay to diagnose SAH. The problem with the chemical assay is that it takes several hours to deliver results and the presence of blood in the spinal fluid sample decreases the test’s accuracy.
Visual inspection of spinal fluid by physicians is another option, but that can be imprecise and is also subject to inaccuracy.
Xanthostat’s test would be an improvement on current practices because it delivers results faster and isn’t as susceptible to accuracy problems caused by blood, according to UC.
UC received a patent on Xanthostat’s core technology last year. The company has transitioned its diagnostic technology from a research-based proof-of-concept to a functional prototype.
Beyette and a UC spokeswoman didn’t respond to inquiries.

Changes in brain's blood flow could cause 'brain freeze'

I just liked this information. Someone with a question and figured out a way to solve it. Where are our stroke researchers on solving stroke questions?
http://www.eurekalert.org/pub_releases/2012-04/aps-cib041912.php

Findings may eventually lead to new treatments for other types of headache

SAN DIEGO— 'Brain freeze' is a nearly universal experience—almost everyone has felt the near-instantaneous headache brought on by a bite of ice cream or slurp of ice-cold soda on the upper palate. However, scientists are still at a loss to explain this phenomenon. Since migraine sufferers are more likely to experience brain freeze than people who don't have this often-debilitating condition, brain freeze may share a common mechanism with other types of headaches, including those brought on by the trauma of blast-related combat injuries in soldiers. One possible link between brain freeze and other headache types is local changes in brain blood flow.
In a new study, Melissa Mary Blatt, Michael Falvo, and Jessica Jasien of the Department of Veterans Affairs New Jersey Health Care System, Brian Deegan and Gearold O Laighin of the National University of Ireland Galway, and Jorge Serrador of Harvard Medical School and the War Related Illness and Injury Study Center of the Veterans Affairs New Jersey Health Care System use brain freeze as a proxy for other types of headaches. By bringing on brain freeze in the lab in volunteers and studying blood flow in their brains, the researchers show that the sudden headache seems to be triggered by an abrupt increase in blood flow in the anterior cerebral artery and disappears when this artery constricts. The findings could eventually lead to new treatments for a variety of different headache types.
An abstract of their study entitled, "Cerebral Vascular Blood Flow Changes During 'Brain Freeze,'" will be discussed at the meeting Experimental Biology 2012 being held April 21-25 at the San Diego Convention Center. The abstract is sponsored by the American Physiological Society (APS), one of six scientific societies sponsoring the conference, which last year attracted some 14,000 attendees.
Bringing on Brain Freeze According to study leader Serrador, previous studies meant to assess what physiological changes might prompt headaches have mainly relied on various drugs, or brought in patients already in the throes of a migraine to the lab. However, both methods have their limitations. Pharmacological agents can induce other effects that can make research results misleading, he says, and since researchers can't wait for migraine sufferers to experience a migraine in the lab, those studies miss the crucial period of headache formation that occurs sometimes hours before scientists were able to study these patients.
To induce headache inside the lab and study it from start to finish, Serrador explains, brain freeze is a perfect fit. It's easy to bring on and resolves quickly without expensive or complicated equipment or drugs.
In this study, Serrador and his colleague recruited 13 healthy adults. The researchers monitored the volunteers' blood flow in several brain arteries using transcranial Doppler while they first sipped ice water with the straw pressed against their upper palate—ideal conditions for bringing on brain freeze—and then while sipping the same amount of water at room temperature. The volunteers raised their hand once they felt the pain of a brain freeze, then raised it again once the pain dissipated. Findings showed that one particular artery, called the anterior cerebral artery, dilated rapidly and flooded the brain with blood in conjunction to when the volunteers felt pain. Soon after this dilation occurred, the same vessel constricted as the volunteers' pain receded.
Changing the Course of Headaches Serrador and his colleagues speculate that the dilation, then quick constriction, may be a type of self-defense for the brain. "The brain is one of the relatively important organs in the body, and it needs to be working all the time," he explains. "It's fairly sensitive to temperature, so vasodilation might be moving warm blood inside tissue to make sure the brain stays warm." But because the skull is a closed structure, Serrador adds, the sudden influx of blood could raise pressure and induce pain. The following vasoconstriction may be a way to bring pressure down in the brain before it reaches dangerous levels.
He notes that similar alterations in blood flow could be at work in migraines, posttraumatic headaches, and other headache types. If further research confirms these suspicions, then finding ways to control blood flow could offer new treatments for these conditions. Drugs that block sudden vasodilation or target channels involved specifically in the vasodilation of headaches could be one way of changing headaches' course.

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About Experimental Biology 2012
Six scientific societies will hold their joint scientific sessions and annual meetings, known as Experimental Biology, from April 21-25, 2012 in San Diego. This meeting brings together the leading researchers from a broad array of life science disciplines. The societies include the American Association of Anatomists (AAA), American Physiological Society (APS), American Society for Biochemistry and Molecular Biology (ASBMB), American Society for Investigative Pathology (ASIP), American Society for Nutrition (ASN), and American Society for Pharmacology and Experimental Therapeutics (ASPET). More information about the meeting can be found online at http://bit.ly/ymb7av.
About the American Physiological Society (APS) The American Physiological Society (APS) is a nonprofit organization devoted to fostering education, scientific research, and dissemination of information in the physiological sciences. The Society was founded in 1887 and today has more than 10,500 members. APS publishes 13 scholarly, peer-reviewed journals covering specialized aspects of physiology. Eleven of the journals are published monthly.