Headaches in intracerebral hemorrhage survivors

Long-term headache after spontaneous intracerebral haemorrhage

BACKGROUND

Though headache is commonly observed after stroke and may affect survivors' quality of life, it has rarely been studied after spontaneous intracerebral haemorrhage (ICH). In a cohort of ICH survivors, we assessed the long-term prevalence and determinants of headache.

METHODS

We screened consecutive ICH survivors enrolled in the prospective, single-centre Prognosis of Intracerebral Haemorrhage study for headache 1, 3, and 6 years after ICH, according to the International Headache Society's criteria. Depressive and anxiety symptoms severity was measured at 1-year follow-up. Variables associated with the presence of headache 1 year after ICH were analyzed using univariate and multivariable models.

RESULTS

Among the 146 patients included in this study, 31 (21%), 25 (19%), and 14 (20%) patients reported headache at 1-, 3-, and 6-year follow-up, respectively. In an age-adjusted model, patients with headache at ICH onset (adjusted odds ratio [aOR] 2.75; 95% CI 1.02-7.42) and previous history of headache (aOR 4.60; 95% CI 1.74-12.1) were associated with headache at 1-year follow-up. Patients with headache were more likely to report depressive and anxiety symptoms at 1-year follow-up (both p < 0.02).

CONCLUSIONS

One in five ICH survivors suffered from headache and patients who reported headache at ICH onset were especially at risk.

Epicranial headache part 1: Primary stabbing headache

BACKGROUND/OBJECTIVE

Primary stabbing headache is a common but under-recognized primary headache disorder. The objectives of this review were to provide practical information for better understanding and identification of the disease, suggest an algorithm for differential diagnosis, and provide an insight into the pathophysiology of primary stabbing headache hypothesized from its clinical course.

METHODS

This narrative review of primary stabbing headache is based on a literature search and the authors' clinical reasoning.

RESULT

The phenotype of each stab is typically abrupt, ultrashort-lasting (<3 s), focal or multifocal, paroxysms of pain occurring sporadically or in clusters. The diagnosis of primary stabbing headache is clinical; fixed or migrating stabs without background pain or sensory abnormalities and the absence of features suggestive of other disorders (e.g., cranial autonomic symptoms or signs) can aid in the diagnosis of primary stabbing headache. The clinical patterns include monophasic, intermittent, and chronic primary stabbing headache, of which the first two are considered typical. The pathophysiology of primary stabbing headache has not yet been elucidated. In this review, we postulated the mechanism of stabbing headache, based on the pain phenotype and clinical course, and provide a clinical algorithm for the differential diagnosis of primary stabbing headache.

CONCLUSION

Knowledge about the typical manifestations and clinical patterns of primary stabbing headache will aid in the proper diagnosis and differential diagnosis. Treatment should be tailored by considering the clinical patterns. Further research is needed to elucidate the pathophysiological mechanisms and optimal treatment of primary stabbing headache.

Characterization of persistent headache attributed to past stroke

BACKGROUND

Persistent headache attributed to past stroke (PHAPS) is a controversial entity, recently included in the third edition of the International Classification of Headache Disorders (ICHD-3) despite being described only in retrospective studies.

OBJECTIVE

To determine the frequency and characteristics of PHAPS in patients admitted with acute stroke.

METHODS

We selected all patients with headache associated with acute stroke (HAAS) from a prospective, single-center registry of patients with acute stroke admitted to a Neurology ward between November 2018 and December 2019. We analyzed demographic, clinical, and neuroimaging data. We assessed the follow-up with a phone call questionnaire at 6 to 12 months.

RESULTS

Among 121 patients with acute stroke, only 29 (24.0%) had HAAS. From these, 6 (5.0%) were lost to follow-up. In total, 23 (20.0%) patients answered the 6- to 12-month follow-up questionnaire and were included in this study. The median age of the sample was 53 years (interquartile range [IQR]: 38-78 years), and there was no sex predominance. Of the 10 patients (8,3%) that had persistent headache, 8 (6.6%) suffered from previous chronic headaches; however, they all mentioned a different kind of headache, and 1 (0,8%) probably had headache secondary to medication.

CONCLUSIONS

In the present study, only 10 out of 121 stroke patients (8.3%) referred persistent headache at the 6- to 12-month follow-up, but the majority already suffered from previous chronic headache, which raises the question that the actual prevalence of PHAPS may be lower than previously reported.

[Headache and cerebrovascular diseases]

Headache is a common symptom of acute and chronic cerebrovascular diseases. Headache can be symptomatic in patients with various forms of vascular pathology of the brain but primary headaches are much more common. Secondary headaches in acute cerebrovascular accidents may be the first symptom, and in some cases, a risk factor or complication of stroke. In chronic cerebrovascular diseases, headache may be the predominant symptom in the early stages and resolve in the later stages of the disease. At the same time, the severity, nature and course of headache cannot be considered as reliable signs of cerebrovascular disease. Meanwhile, the verification of the headache form is important from the point of view of determining the priorities of diagnosis and therapy.

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.

Poststroke Pain

Pain is common but often underrecognized after stroke. Poststroke pain (PSP) hinders recovery, impairs quality of life, and is associated with the psychological state of patients with stroke. The most common subtypes of PSP include central PSP, complex regional pain syndrome, shoulder pain, spasticity-related pain, and headache. The pathophysiologies of these PSP subtypes are not yet clearly understood, and PSP is refractory to conventional treatment in many patients. However, recent studies have proposed potential pathophysiologies of PSP subtypes, which may help prioritize therapies that target specific mechanisms.

Headache at the Chronic Stage of Ischemic Stroke

BACKGROUND

Headache in ischemic stroke survivors after the acute stage is incompletely described.

OBJECTIVE

We aimed to prospectively describe the characteristics of headache and the predictors of headache at the chronic stage after ischemic stroke.

METHODS

We conducted a prospective observational cohort study including 102 acute ischemic stroke patients admitted to a Stroke Unit. Patients were interviewed at the acute and the chronic stage (12 months after stroke). Characteristics of those headaches were collected using a previously validated headache questionnaire enabling headache classification following the International Headache Society criteria. Pre-stroke headache history was registered using the same instrument.

RESULTS

Forty-five patients out of 89 with completed follow-up (51%) reported headache at the chronic stage. In most of the patients, headache was sporadic, mild, pressure-like, with a duration of minutes to hours, with characteristics of tension-type headache in 51% (n = 23/45). Headache was a reactivation of pre-stroke headache in 33% (n = 15/45), different from pre-stroke headache in 44% (n = 20/45), and of new-onset in 22% (n = 10/45). Only 1 patient had a new-onset headache at the acute stage that persisted with the same characteristics at the chronic stage. Pre-stroke headache (OR = 5.3; 95% CI [2.01-13.98] P = .001) and female sex (OR = 3.5; 95% CI [1.3-9.4] P = .013) predicted headache at the chronic stage after stroke, controlling for age, severity, and location of stroke.

CONCLUSIONS

Headache in ischemic stroke survivors at the chronic stage is more frequent in women and in patients with pre-stroke headache. It is most frequently a headache with different characteristics of the pre-stroke headache and only rarely a new-onset headache starting at the acute stage and persisting at the chronic stage.

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.

Spreading Depression in Primary and Secondary Headache Disorders

PURPOSE OF REVIEW

Spreading depression (SD) is a wave of simultaneous and near-complete depolarization of virtually all cells in brain tissue associated with a transient "depression" of all spontaneous or evoked electrical activity in the brain. SD is widely accepted as the pathophysiological event underlying migraine aura and may play a role in headache pathogenesis in secondary headache disorders such as ischemic stroke, subarachnoid or intracerebral hemorrhage, traumatic brain injury, and epilepsy. Here, we provide an overview of the pathogenic mechanisms and propose plausible hypotheses on the involvement of SD in primary and secondary headache disorders.

RECENT FINDINGS

SD can activate downstream trigeminovascular nociceptive pathways to explain the cephalgia in migraine, and possibly in secondary headache disorders as well. In healthy, well-nourished tissue (such as migraine), the intense transmembrane ionic shifts, the cell swelling, and the metabolic and hemodynamic responses associated with SD do not cause tissue injury; however, when SD occurs in metabolically compromised tissue (e.g., in ischemic stroke, intracranial hemorrhage, or traumatic brain injury), it can lead to irreversible depolarization, injury, and neuronal death. Recent non-invasive technologies to detect SDs in human brain injury may aid in the investigation of SD in headache disorders in which invasive recordings are not possible. SD explains migraine aura and progression of neurological deficits associated with other neurological disorders. Studying the nature of SD in headache disorders might provide pathophysiological insights for disease and lead to targeted therapies in the era of precision medicine.

Development of persistent headache following stroke: A 3-year follow-up

Background

Headache following stroke has been described in previous studies with an incidence of 23%–54%, but a clear description of headache developing after stroke onset is still lacking. The aim of this study was to determine the incidence and characteristics of persistent novel headache after stroke and to describe the use of medication, including dipyridamole.

Methods

As a follow-up to a prospective study, a standardized questionnaire about characteristics of novel headache and medication use was sent out to surviving patients three years after their stroke.

Results

The questionnaire was sent to 256 patients and returned by 222, of whom 12% (26/222) of patients reported persistent novel headache. Dipyridamole had no significant influence on the incidence. Stroke-attributed headache according to predefined criteria was reported in 7.2% (16/222) of patients, with tension-type-like headache in 50.0%, migraine-like in 31.3% and medication overuse in 6.25% of patients. More than half of patients experienced moderate to severe pain and had a score of 55 or above on the Headache Impact Test-6 scale.

Conclusion

Novel headache after stroke affects one in 10 patients and seems to be unrelated to dipyridamole use. Persistent headache attributed to stroke is similar to tension-type headache for half of patients.

Pain following stroke: a prospective study

BACKGROUND

Post-stroke pain is common and affects the quality of life of stroke survivors, but the incidence and severity of headache, shoulder pain, other joint pain and central post-stroke pain following stroke still remain unclear. The aim of this prospective study was to determine the incidence and intensity of these different types of post-stroke pain.

METHODS

A total of 299 consecutive stroke patients, admitted to the Department of Neurology at Aarhus University Hospital, underwent a structured interview and a short sensory examination within 4 days of admission. Follow-up was conducted by phone 3 and 6 months after stroke onset, with 275 patients completing the whole study. Pain with onset in relation to stroke onset or following stroke was defined as 'newly developed pain'.

RESULTS

At the 6-month follow-up, newly developed pain was reported by 45.8% of the patients; headache by 13.1%, shoulder pain by 16.4%, other joint pain by 11.7%, other pain by 20.0% and evoked pain by light touch or thermal stimuli by 8.0%. More than one pain type was reported by 36.5% of the patients with newly developed pain. According to pre-defined criteria, 10.5% of the patients were classified as having possible central post-stroke pain. There was a moderate to severe impact on daily life in 33.6% of the patients with newly developed pain.

CONCLUSIONS

Pain following stroke is common, with almost half of the patients reporting newly developed pain 6 months after stroke.

Transient stabbing headache from an acute thalamic hemorrhage

Stabbing headache can be encountered in both primary and secondary forms, but has been infrequently reported among patients with stroke, and is not known to be associated with a small well-circumscribed brain lesion. A 95-year-old woman taking warfarin presented with the sudden onset of stabbing headache strictly in the right frontal and supraorbital regions, along with gait imbalance and dysarthria. Neuroimaging revealed a small left thalamic hematoma. This association of an acute thalamic lesion with stabbing headache in the contralateral trigeminal distribution is discussed, along with a brief review of stabbing headache occurring in cerebrovascular disease.

Stroke-Related Headache: A Clinical Study in Lacunar Infarction

OBJECTIVE

To describe the characteristics of headache related to lacunar stroke based on data collected from a prospective hospital-based stroke registry over a 12-year period. Demographics, clinical variables, and prognostic features of lacunar stroke in patients with and without headache are compared.

BACKGROUND

Stroke-related headache has been largely investigated, but there is little clinical data on headache in individualized stroke subtypes.

METHODS

The cohort of 484 patients with lacunar infarction was selected. Forty-five (9.3%) presented headache within a 72-hour interval of stroke onset. Predictors of lacunar infarction with headache were assessed by logistic regression analysis.

RESULTS

The intensity of headache was mild in severity and poorly localized (diffuse or bilateral headache). Tension-type headache was present in 36 patients (80%) and 9 patients (20%) presented nausea or vomiting while experiencing mild pulsating pain. The frequency of headache was 17% in patients with atypical lacunar syndrome, 12% in dysarthria-clumsy hand, 11.5% in pure sensory stroke, 9.4% in sensorimotor stroke, and 7.1% in pure motor hemiparesis. When patients with lacunar infarction with and without headache were compared, female sex, diabetes mellitus, nausea and vomiting, and mesencephalic topography were significantly more frequent and dysarthria and frequency of symptom free at discharge were less frequent in the headache group. In the multivariate analysis, mesencephalic topography (odds ratio [OR] 16.62), nausea and vomiting (OR 13.27), sex female (OR 2.29), diabetes mellitus (OR 1.96), and age (OR 0.95) were predictors of lacunar infarction with headache.

CONCLUSIONS

Headache at the onset of a lacunar infarction is uncommon. Mesencephalic topography, nausea and vomiting, female sex, diabetes, and age were independent variables significantly associated with lacunar infarction with headache. These findings contribute to knowledge of stroke-related headache in patients with lacunes.

Hereditary inclusion body myopathies

Hereditary inclusion body myopathies comprise autosomal recessive and autosomal dominant muscle disorders that have a variable clinical phenotype but share similar morphological features. These include rimmed vacuoles within muscle fibres and collections of intrasarcoplasmic and intranuclear tubulofilamentous inclusions, 16-18 nm in external diameter. The resemblances and the differences between the sporadic and the hereditary inclusion body myopathies are discussed. Recent advances in the identification of various proteins involved in these diseases are mentioned because they have provided better insight into their underlying pathophysiological mechanisms. Linkage studies have allowed the localization of the genetic defect of some hereditary inclusion body myopathies and related disorders, contributing to their individualization.