Headache as a symptom at stroke onset in 4,431 young ischaemic stroke patients. Results from the “stroke in young fabry patients (SIFAP1) study”

Headache due to Vascular Disorders

Headache and cerebrovascular disease (CVD) are inextricably linked. Although in some cases headache complicating CVD may be little more than a symptomatic afterthought, in other cases, early recognition of headache's role in the CVD process is critical to effective management. In other words, headaches secondary to CVD span a spectrum, and in this article, we will review that spectrum.

[Imaging in headache]

Headache is worldwide one of the leading reasons to consult a general practitioner or a neurologist. In addition to the medical history and results of laboratory parameters, imaging represents one of the most important diagnostic steps. As there is a myriad of possible causes, it is nearly impossible to cover the whole spectrum of this topic. This article summarizes the most important morphological imaging findings and their pitfalls.

Acute headache attributed to ischemic stroke: assessment of its characteristics and associated factors

BACKGROUND

 It is estimated that headache attributed to ischemic stroke occurs in 7.4% to 34% of the cases. Despite its frequency, this headache has been little studied in terms of its risk factors and characteristics.

OBJECTIVE

 To assess the frequency and clinical characteristics of headache attributed to ischemic stroke and the factors associated with its occurrence.

METHODS

 The present was a cross-sectional study which included patients consecutively admitted within 72 hours of the onset of ischemic stroke. A semi-structured questionnaire was used. The patients underwent magnetic resonance imaging.

RESULTS

 A total of 221 patients were included, 68.2% of whom were male, and the mean age was of 68.2 ±  13.8 years. The frequency of headache attributed to ischemic stroke was of 24.9% (95% confidence interval [95%CI]: 19.6-31.1%). The headache had a median duration of 21 hours and most frequently began at the same time as the focal deficit (45.3%), with a gradual onset (83%). It was of moderate intensity, pulsatile (45.3%), bilateral (54.6%), and presented a similar pattern to that of tension-type headache (53.6%). Headache attributed to stroke was significantly associated with previous tension-type headache, and previous migraine with and without aura (logistic regression).

CONCLUSION

 Headache attributed to stroke is common, with a pattern similar to that of tension-type headache, and it is associated with a history of tension-type and migraine headaches.

Association of concomitant headache with hypoperfusion in ischemic stroke: A multimodal CT-based study

Previous investigations indicate that vessel wall elasticity may contribute to the occurrence of an ischemic stroke-associated headache. In this prospective study, the association between radiologic parameters of intracranial hemodynamic changes and concomitant headaches during the early phase of ischemic stroke was examined. Consecutive patients with acute ischemic stroke (AIS) from the First Affiliated Hospital of Soochow University were recruited and divided into two groups according to their questionnaire results and the International Classification of Headache Disorder 3 criteria. Baseline data, including stroke sub-types and neurological function, at admission and discharge were collected. Non-contrast computed tomography (CT), CT angiography, and CT perfusion were performed to assess intracranial hemodynamic changes. Multiple adjusted logistic models were used and possible confounding factors were included in sequential models. A total of 190 patients with AIS (93 headaches and 97 non-headache) were recruited. There were significant differences between the two groups in gender, hypertension, Alberta stroke program early CT score, relative cerebral blood flow (rCBF), and relative cerebral blood volume (rCBV). Furthermore, rCBV (adjusted odds ratio [OR] 0.160; 95% confidence interval [CI], 0.055-0.461; p < 0.001) and rCBF (adjusted OR, 0.309; 95% CI, 0.113-0.844; p < 0.05) were significantly associated with concomitant headache during the early phase of AIS in fully adjusted models. After adjusting for sociodemographic characteristics and other confounding factors, p values for the ORs were robust and intensified. Patients with lower rCBV and rCBF tended to experience the concomitant headache during the early phase of AIS. Regional hypoperfusion and microcirculation might play an important role in this separate clinical entity.

Differences in the pre-hospital management of women and men with stroke by emergency medical services in New South Wales

OBJECTIVES

To examine whether pre-hospital emergency medical service care differs for women and men subsequently admitted to hospital with stroke.

DESIGN, SETTING, PARTICIPANTS

Population-based cohort study; analysis of linked Admitted Patient Data Collection and NSW Ambulance data for people admitted to New South Wales hospitals with a principal diagnosis of stroke at separation, 1 July 2005 - 31 December 2018.

MAIN OUTCOME MEASURES

Emergency medical service assessments, protocols, and management for patients subsequently diagnosed with stroke, by sex.

RESULTS

Of 202 231 people hospitalised with stroke (mean age, 73 [SD, 14] years; 98 599 women [51.0%]), 101 357 were conveyed to hospital by ambulance (50.1%). A larger proportion of women than men travelled by ambulance (52.4% v 47.9%; odds ratio [OR], 1.09; 95% CI, 1.07-1.11), but time between the emergency call and emergency department admission was similar for both sexes. The likelihood of being assessed as having a stroke (adjusted OR [aOR], 0.97; 95% CI, 0.93-1.01) or subarachnoid haemorrhage (aOR, 1.22; 95% CI, 0.73-2.03) was similar for women and men, but women under 70 years of age were less likely than men to be assessed as having a stroke (aOR, 0.89; 95% CI, 0.82-0.97). Women were more likely than men to be assessed by paramedics as having migraine, other headache, anxiety, unconsciousness, hypertension, or nausea. Women were less likely than men to be managed according to the NSW Ambulance pre-hospital stroke care protocol (aOR, 0.95; 95% CI, 0.92-0.97), but the likelihood of basic pre-hospital care was similar for both sexes (aOR, 1.01; 95% CI, 0.99-1.04).

CONCLUSION

Our large population-based study identified sex differences in pre-hospital management by emergency medical services of women and men admitted to hospital with stroke. Paramedics should receive training that improves the recognition of stroke symptoms in women.

Call to Action for Enhanced Equity: Racial/Ethnic Diversity and Sex Differences in Stroke Symptoms

Background

Fundamental aspects of human identity may play a role in the presentation of stroke symptoms and, consequently, stroke recognition. Strokes must be recognized and treated expeditiously, as delays result in poorer outcomes. It is known that sex plays a role in the presentation of symptoms, such that non-traditional symptoms are more commonly observed among women. However, factors such as geographical location and race/ethnicity, and the interactions between these various factors, need to be considered. This will provide an intersectional approach.

Methods

A systematic review and meta-analysis of the literature was conducted to investigate differences in the presentation of stroke symptoms between sexes. Using PubMed and Embase, a search involving the components sex, symptoms and stroke was completed and yielded 26 full-text manuscripts.

Results

Our findings indicate that there is substantial overlap in stroke symptom presentation in men and women. Nonetheless, some differences in the clinical manifestations of stroke were observed. In addition, it was discovered that only three studies were conducted outside of North America and Europe. Furthermore, only two studies reported symptoms based on both sex and racial/ethnic group.

Conclusion

These findings indicate a research gap and call for increased research in order to uncover the possible interactions between sex and race/ethnicity in an intersectional approach. Resultantly, stroke recognition could be improved and greater equity in healthcare can be achieved.

Headache secondary to cerebrovascular disease

OBJECTIVES

To discuss headache secondary to cerebrovascular disease.

BACKGROUND

Headache is an important symptom in cerebrovascular diseases. In some conditions, headache is the leading symptom. Migraine is associated with an increased risk of stroke.

METHODS

The authors undertook a literature search for the terms "headache" and "cerebrovascular diseases".

RESULTS

We report studies on headache in subarachnoidal hemorrhage, intracerebral hemorrhage, ischemic stroke, TIA, basilar artery thrombosis, cervical artery dissection, cerebellar stroke, arteritis and cerebral sinus venous thrombosis. In addition, we discuss migraine and stroke and thunderclap headache.

CONCLUSIONS

Headache is a leading symptom in many cerebrovascular diseases. Headache in combination with focal neurological deficits requires immediate diagnosis and treatment.

Headache at onset of first-ever ischemic stroke: Clinical characteristics and predictors

No studies have prospectively investigated headache at onset of first-ever ischemic stroke along with a large concurrent control group. Our aims were to answer two important questions: (i) Are headaches at stroke onset causally related to the stroke, and what are their typical clinical characteristics? (ii) What etiology of stroke is associated with these headaches? The study population consisted of 550 patients (mean age = 63.1, 54% males) with first-ever ischemic stroke and 192 control patients (mean age = 58.7, 36% males) admitted to the emergency room without any acute neurological deficits or serious disorders. All data were collected prospectively, using a standardized case-report form during face-to-face interviews by neurologists. Headache at onset of ischemic stroke was present in 82 (14.9%) of 550 patients. More than half (56%) had a new type of headache (mainly migraine-like) simultaneously with stroke onset, and 36% had headache with altered characteristics (mainly tension-type-like headache). Headaches were associated with cardioembolism (p = 0.002, odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.4-4.1), posterior circulation stroke (p = 0.01, OR = 2.0, 95% CI = 1.2-3.5), infarcts >15 mm (p = 0.03, 95% CI = 1.1-2.7), infarcts of the cerebellum (p = 0.02, OR = 2.3, 95% CI = 1.1-4.8), good neurological status (p = 0.01, OR = 2.5, 95% CI = 1.2-4.9), and low frequency of large-artery atherosclerosis (p = 0.004, OR = 0.4, 95% CI = 0.2-0.8). At stroke onset, headache of a new type and headache with altered characteristics were related to ischemic stroke. They were associated with certain etiologies of stroke.

Headache after ischemic stroke: A systematic review and meta-analysis

Objective

Headache associated with ischemic stroke is poorly understood. To gain further insight, we systematically reviewed studies examining the prevalence and characteristics of new-onset poststroke headache.

Methods

Medline and PubMed databases were queried. A total of 1,812 articles were identified. Of these, 50 were included in this systematic review. Twenty were included in a meta-analysis and meta-regression.

Results

Headache occurred in 6%–44% of the ischemic stroke population. Most headaches had tension-type features, were moderate to severe, and became chronic in nature. Meta-analysis using an inverse-variance heterogeneity model revealed a pooled prevalence of 0.14 (95% confidence interval [CI] 0.07–0.23) with heterogeneity among studies. Metaregression revealed a significant association between prevalence and study location, the source population's national human development index (HDI), and study quality. We found higher prevalence in European (0.22, 95% CI 0.14–0.30) and North American (0.15, 95% CI 0.05–0.26) studies compared with Middle Eastern and Asian studies (0.08, 95% CI 0.01–0.18). However, within each region, populations from countries with higher HDI (p = 0.03) and studies with higher quality (p = 0.001) had lower prevalence. Calculated crude odds ratios (ORs) showed that posterior circulation stroke (pooled OR 1.92, 95% CI 1.4–2.64; n = 7 studies) and female sex (pooled OR 1.25, 95% CI 1.07–1.46; n = 11 studies) had greater odds of headache associated with ischemic stroke.

Conclusions

Taken together, these data suggest that headache is common at the onset of or shortly following ischemic stroke and may contribute to poststroke morbidity. Better understanding of headache associated with ischemic stroke is needed to establish treatment guidelines and inform patient management.

A Narrative Review of Persistent Post-Stroke Headache - A New Entry in the International Classification of Headache Disorders, 3rd Edition

BACKGROUND

Persistent post-stroke headache is a clinical entity that has recently entered the International Classification of Headache Disorders, 3rd edition. In contrast to acute headache attributed to stroke, the epidemiology, clinical features, potential pathophysiology, and management of persistent post-stroke headache have not been reviewed.

METHODS

We summarize the literature describing persistent headache attributed to stroke.

RESULTS

Persistent headache after ischemic or hemorrhagic stroke affects up to 23% of patients. These persistent headaches tend to have tension-type features and are more frequent and severe than acute stroke-related headaches. Risk factors include younger age, female sex, pre-existing headache disorder, and comorbid post-stroke fatigue or depression. Other factors including obstructive sleep apnea or musculoskeletal imbalances may contribute to headache persistence. Although more evidence is needed, it may be reasonable to treat persistent post-stroke headache according to headache semiology.

CONCLUSION

Recognition of persistent post-stroke headache as a separate clinical entity from acute stroke-attributed headache is the first step toward better defining its natural history and most effective treatment strategies.

Headache in stroke according to National Acute Stroke Israeli Survey

OBJECTIVES

Analysis of headache occurrence in a national cohort of patients with acute stroke.

METHODS

The data were based on the triennial 2-month period of the National Acute Stroke Israeli (NASIS) Registry. A total of 2166 patients with acute stroke were retrieved: 2001 (92.4%) had ischemic stroke (IS), 150 (6.9%) had intracerebral hemorrhage (ICH), 4 (0.2%) had sinus vein thrombosis (SVT), where as in 11 (0.5) the stroke type was undetermined.

RESULTS

Two hundred and six (9.5%) patients reported headache: in SVT headache was reported by 50% of patients, in ICH by 21.3% while 8.4% of patients with IS (28% with transient ischemic attack [TIA]) complained about headache. In 18.1% of patients with headache, the stroke type was undetermined. Female gender, younger age, previous headache, cerebral hemorrhage, and dizziness/unsteadiness predisposed for headache. The incidence of headache was higher in patients with ICH than in patients with IS regardless of the history of previous headaches. In IS, headache decreased with stroke severity and was more common in the posterior than in the anterior circulation. Patients with lacunar stroke suffered less frequently from headache than patients with non-lacunar stroke. Significantly more patients with carotid dissection presented with headache than without.

CONCLUSIONS

Intracerebral hemorrhage, younger age, female gender, posterior circulation involvement, and headache history are predictors for headache occurrence in acute stroke. Headache incidence in ICH correlates with stroke severity as opposed to IS. Headache in TIA is not unusual. Lacunar strokes are generally not accompanied by headaches. Headache remains the main complaint in SVT and carotid dissection.

Role of atherosclerosis, clot extent, and penumbra volume in headache during ischemic stroke

OBJECTIVE

To investigate the role of large vessel atherosclerosis, blood clot extent, and penumbra volume in relation to headache in ischemic stroke patients.

METHODS

In this cross-sectional study, we performed noncontrast CT, CT angiography (CTA), and CT perfusion (CTP) in 284 participants from the Dutch Acute Stroke Study and Leiden Stroke Cohort within 9 hours after ischemic stroke onset. We collected headache characteristics prospectively using a semi-structured questionnaire. Atherosclerosis was assessed by evaluating presence of plaques in extracranial and intracranial vessels and by quantifying intracranial carotid artery calcifications. Clot extent was estimated by the clot burden score on CTA and penumbra volume by CTP. We calculated risk ratios (RRs) with adjustments (aRR) for possible confounders using multivariable Poisson regression.

RESULTS

Headache during stroke was reported in 109/284 (38%) participants. Headache was less prevalent in patients with than in patients without atherosclerosis in the extracranial anterior circulation (35% vs 48%; RR 0.72; 95% confidence interval [CI] 0.54-0.97). Atherosclerosis in the intracranial arteries was also associated with less headache, but this association was not statistically significant. Penumbra volume (aRR 1.08; 95% CI 0.63-1.85) and clot extent (aRR 1.02; 95% CI 0.86-1.20) were not related with headache.

CONCLUSIONS

Headache in the early phase of ischemic stroke tends to occur less often in patients with atherosclerosis than in patients without atherosclerosis in the large cerebral arteries. This finding lends support to the hypothesis that vessel wall elasticity is a necessary contributing factor in the occurrence of headache during acute ischemic stroke.

Cervical artery dissection in young adults in the stroke in young Fabry patients (sifap1) study

BACKGROUND

Patients with carotid artery dissection (CAD) have been reported to have different vascular risk factor profiles and clinical outcomes to those with vertebral artery dissection (VAD). However, there are limited data from recent, large international studies comparing risk factors and clinical features in patients with cervical artery dissection (CeAD) with other TIA or ischemic stroke (IS) patients of similar age and sex.

METHODS

We analysed demographic, clinical and risk factor profiles in TIA and IS patients ≤55 years of age with and without CeAD in the large European, multi-centre, Stroke In young FAbry Patients 1 (sifap1) study. Patients were further categorised according to age (younger: 18-44 years; middle-aged: 45-55 years), sex, and site of dissection.

RESULTS

Data on the presence of dissection were available in 4,208 TIA and IS patients of whom 439 (10.4%) had CeAD: 196 (50.1%) had CAD, 195 (49.9%) had VAD, and 48 had multiple artery dissections or no information regarding the dissected artery. The prevalence of CAD was higher in women than in men (5.9 vs. 3.8%, p < 0.01), whereas the prevalence of VAD was similar in women and men (4.6 vs. 4.7%, n.s.). Patients with VAD were younger than patients with CAD (median = 41 years (IQR = 35-47 years) versus median = 45 years (IQR = 39-49 years); p < 0.01). At stroke onset, about twice as many patients with either CAD (54.0 vs. 23.1%, p < 0.001) or VAD (63.4 vs. 36.6%, p < 0.001) had headache than patients without CeAD and stroke in the anterior or posterior circulation, respectively. Compared to patients without CeAD, hypertension, concomitant cardiovascular diseases and a patent foramen ovale were significantly less prevalent in both CAD and VAD patients, whereas tobacco smoking, physical inactivity, obesity and a family history of cerebrovascular diseases were found less frequently in CAD patients, but not in VAD patients. A history of migraine was observed at a similar frequency in patients with CAD (31%), VAD (27.8%) and in those without CeAD (25.8%).

CONCLUSIONS

We identified clinical features and risk factor profiles that are specific to young patients with CeAD, and to subgroups with either CAD or VAD compared to patients without CeAD. Therefore, our data support the concept that certain vascular risk factors differentially affect the risk of CAD and VAD.