Concomitant Headache Influences Long-term Prognosis After Acute Cerebral Ischemia of Noncardioembolic Origin

Frequency, characteristics, and predictors of headache attributed to acute ischemic stroke

OBJECTIVES

Although headache is a common symptom in acute ischemic stroke, the clinical and radiological factors associated with its occurrence are controversial. This work aimed to determine the frequency, characteristics, and predictors of headache occurrence among patients with acute ischemic stroke.

METHODS

This cross-sectional study was conducted on 303 patients with acute ischemic stroke. The patients were submitted to detailed history taking, clinical and radiological assessment. A detailed analysis of headache was performed for the patients who experienced headache temporally related to stroke onset.

RESULTS

Diagnosis of headache attributed to the ischemic stroke was established in 129 (42.6%) patients; sentinel headache in 17.2% of patients, and headache at stroke onset in 25.4% of patients. The headache group had a significantly younger age (P=0.017), lower NIHSS score (P=0.042), higher frequency of pre-existing headache disorders (P=0.001), substance use disorder (P=0.021), and fever (P=0.036), and lower frequency of chronic hypertension (P=0.013) and small vessel disease (P=0.004) than non-headache group. Infarction involving posterior circulation was more frequent in headache than in non-headache groups (P=0.003). The presence of migraine, tension-type headache, other types of headache, fever and posterior circulation stroke increased the odds of headache by 27.4 (95%CI=8.0-94.4), 7.6 (95%CI=3.93-14.6), 26.2 (95%CI=8.0-85.8), 3.75 (95%CI=1.22-11.6) and 3.15 (95%CI=1.65-6.0) times, respectively, whereas, the presence of small vessel disease decreased the odds of headache by 0.51 (95%CI=0.279-0.95) times.

CONCLUSION

Pre-existing headache disorder, fever, and posterior circulation stroke were associated with headache occurrence in acute ischemic stroke patients.

Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Women have worse outcomes than men after stroke. Differences in presentation may lead to misdiagnosis and, in part, explain these disparities. We investigated whether there are sex differences in clinical presentation of acute stroke or transient ischemic attack.

METHODS

We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Inclusion criteria were (1) cohort, cross-sectional, case-control, or randomized controlled trial design; (2) admission for (suspicion of) ischemic or hemorrhagic stroke or transient ischemic attack; and (3) comparisons possible between sexes in ≥1 nonfocal or focal acute stroke symptom(s). A random-effects model was used for our analyses. We performed sensitivity and subanalyses to help explain heterogeneity and used the Newcastle-Ottawa Scale to assess bias.

RESULTS

We included 60 studies (n=582 844; 50% women). In women, headache (pooled odds ratio [OR], 1.24 [95% CI, 1.11-1.39]; I²=75.2%; 30 studies) occurred more frequently than in men with any type of stroke, as well as changes in consciousness/mental status (OR, 1.38 [95% CI, 1.19-1.61]; I²=95.0%; 17 studies) and coma/stupor (OR, 1.39 [95% CI, 1.25-1.55]; I²=27.0%; 13 studies). Aspecific or other neurological symptoms (nonrotatory dizziness and non-neurological symptoms) occurred less frequently in women (OR, 0.96 [95% CI, 0.94-0.97]; I²=0.1%; 5 studies). Overall, the presence of focal symptoms was not associated with sex (pooled OR, 1.03) although dysarthria (OR, 1.14 [95% CI, 1.04-1.24]; I²=48.6%; 11 studies) and vertigo (OR, 1.23 [95% CI, 1.13-1.34]; I²=44.0%; 8 studies) occurred more frequently, whereas symptoms of paresis/hemiparesis (OR, 0.73 [95% CI, 0.54-0.97]; I²=72.6%; 7 studies) and focal visual disturbances (OR, 0.83 [95% CI, 0.70-0.99]; I²=62.8%; 16 studies) occurred less frequently in women compared with men with any type of stroke. Most studies contained possible sources of bias.

CONCLUSIONS

There may be substantive differences in nonfocal and focal stroke symptoms between men and women presenting with acute stroke or transient ischemic attack, but sufficiently high-quality studies are lacking. More studies are needed to address this because sex differences in presentation may lead to misdiagnosis and undertreatment.

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.

The Headache and Neck Pain in Ischemic Stroke Patients Caused by Cervicocerebral Artery Dissection. A Case-Control Study

BACKGROUND AND PURPOSE

The symptom of headache and neck pain is common in patients with cervicocerebral artery dissection (CAD). We attempt to screen ischemic stroke patients with CAD based on the characteristics of the pain.

METHODS

Eighty-one consecutive ischemic stroke patients with CAD from 2010 to 2017 and 84 consecutive ischemic stroke patients with large artery atherosclerosis (LAA) were registered prospectively and observed in Zhengzhou, China. Those ischemic stroke patients complained of headache and neck pain were categorized into 2 groups. By analyzing the difference of headache and neck pain in 2 groups, we summarized characteristics of the pain secondary to CAD.

RESULTS

There were 34 patients in CAD group and 19 patients in LAA group. As for patients in CAD group, the pain could be located in the ipsilateral (41.9%), bilateral (41.9%), or contralateral (16.1%) side of the dissected artery, but in LAA group the pain was often in both sides (68.4%). When the dissected artery was involved in anterior circulation, 55.6% of CAD patients had pain in temporal and when involved in posterior circulation, 65.2% of CAD patients had pain in the occipital and neck. Patients with CAD had a higher prevalence of throbbing pain (30.0%), while pulsating pain (43.8%) was more common in LAA group. Patients often presented with severe pain (46.9%) in CAD group, while less frequently (11.8%) in LAA group, with a significant difference (P = .003). And there was a significant difference between the length (≥20 mm) of the involved artery and severity of the pain (P = .028) in CAD group.

CONCLUSIONS

Ischemic stroke patients caused by CAD tend to suffer from headache and neck pain, which may be severe and throbbing, compared with those resulting from LAA. The anterior circulation dissection has a higher prevalence of temporal pain while posterior circulation dissection is typically more associated with occipital and neck pain.

Headache and Its Approach in Today's NeuroIntensive Care Unit

Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.

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.