Review
Headache in ischaemic stroke
Senthil Raghunathan MD, MRCP, Bella Richard MSc, FRCP, Pradeep Khanna MBE, FRCP
Causes and clinical characteristics of
headache in ischaemic stroke
Headache is a common symptom of all types of stroke,including ischaemic stroke,but it is often overlooked
as a result of clinicians concentrating on other clinical signs and the further management of the patient.
In this article,the authors discuss the prevalence,possible aetiology and clinical characteristics of headache
in ischaemic stroke.
S
Stroke is the third most common cause of death and
the single most common cause of severe disability in
developed countries. Headache is a relatively common
symptom associated with cerebrovascular disease,
with a prevalence varying between 24 and 54 per cent1
depending on the type and location of the cerebrovas-
cular event. Headache is well known to be associated
with various types of stroke, including intracranial
haemorrhage, subarachnoid haemorrhage, giant cell
arteritis, carotid or vertebral arterial dissection, migra-
nous strokes, meningitis and intracranial venous sinus
thrombosis.2
Headache is a frequently overlooked symptom in
ischaemic stroke and studies investigating its char-
acteristics and clinical implications are limited. This
review article focuses on headache in various types
of ischaemic stroke, its epidemiology, aetiology, asso-
ciated clinical factors and characteristics.
Headache in various types of stroke
The incidence of headache in ischaemic stroke is esti-
mated to vary from 25-29 per cent,3 from the limited,
mostly retrospective studies carried out so far. This is
likely to be an underestimate, as a significant propor-
tion of patients in these studies could not respond due
to aphasia or altered mental status secondary to under-
lying stroke.1
Headache is more frequently associated with
haemorrhagic stroke (34-60 per cent) than ischaemic
stroke.4 Headache is also more commonly associated
with transient ischaemic attacks (TIAs) than
ischaemic stroke, with incidence rates of 25-44 per
cent5 reported in various studies.
Ischaemic stroke in the basilar distribution area,
especially the posterior cerebral circulation, is more
often associated with headache than stroke in the
carotid distribution area.6
Headache is more frequently associated with:1
• Haemorrhagic stroke than infarcts
• Posterior than anterior circulation infarcts
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• Thrombotic than embolic ischaemic events
• Cortical than deep white matter infarcts
• Venous than arterial infarction.
Table 1 shows the prevalence of headache in dif-
ferent types of stroke1 and Table 2 shows the preva-
lence of headache in ischaemic stroke according to
the artery involved in the infarct.7
Aetiology
Several hypotheses exist regarding the cause of
headaches in stroke but the exact aetiology remains
unclear. Most studies confirm that stroke in the pos-
terior cerebral circulation is more often associated
with headache. One possible reason could be the
presence of heavily inner vated pain sensitive ves-
sels at the base of the brain,8 leading to activation
of nociceptive trigeminovascular afferents resulting
in headache.
Another hypothesis is that the pain is caused by
vasodilatation of arteries9 following emboli/thrombus
formation at the base of the brain or occlusion of sev-
eral arterial branches, leading to changes in vascular
perfusion. This mechanism could explain headaches
in embolic or thrombotic strokes but does not explain
its occurrence in TIA.
A further suggestion is that headache may be
caused by release of vasoactive substances, such as
serotonin and prostaglandins, from activated platelets.10
This hypothesis would certainly explain a lower inci-
dence of headaches in patients with small deep lesions,
where platelet activation has not been demonstrated.
Headache in vertebrobasilar stroke is more often
a migraine-type pain, which suggests that migraine
and stroke share a common pathological neural mech-
anism in their underlying cause.8
Association with clinical factors
Headache is a common symptom in acute stroke, but
its association with clinical factors differs according
to various studies. The largest study to date, carried
Progress in Neurology and Psychiatry 21
Review
Headache in ischaemic stroke

Type of stroke
Haemorrhagic stroke
Transient ischaemic attack
Infarction: thrombotic
Infarction: embolic
Lacunar infarct
Table 1. Prevalence of headache according to type of
cerebrovascular lesion9
Prevalence of stroke severity measured by the modified Rankin scale
at one week after the event. Vascular risk factors, such
headache
as hypertension and cigarette smoking, and also time
of the day, did not show a significant association with
23-60% headache at stroke onset.
25-44%
5-31% International Headache Society classification
18-25% The International Headache Society (IHS) classifies
4-11% headache associated with ischaemic cerebrovascular
disease as:12
• IHS 6.1.1 – headache attributed to ischaemic stroke
(cerebral infarction); or
• IHS 6.1.2 – headache attributed to TIA.

Artery involved in infarct Prevalence of Diagnostic criteria

headache
Posterior cerebral artery 64-90%
Vertebral artery 68%
Basilar artery 21-53%
Middle cerebral artery 10-39%
Anterior cerebral artery 0-18%
Table 2. Prevalence of headache in ischaemic stroke
according to the artery involved in the infarct10
out by Tentscher t et al. in 2005, 11 involving 2196
patients with ischaemic stroke, found that:
• Patients less than 40 years old had a four-fold
increased risk of headache at stroke onset compared
with patients aged 80 years and older. The probability
of developing headache decreased steadily with
increasing age.
• Women were more likely to develop headache at
stroke onset than men.
• Previous history of migraine especially with aura
was strongly associated with headache at stroke onset,
as shown in various other studies.
• For reasons unknown, patients with right hemi-
spheric ischaemic stroke had a higher prevalence of
headache than left hemispheric lesions.
• Results also confirmed the association of headache
with vertebrobasilar stroke found in previous studies;
however, headache was par ticularly prevalent in
patients with cerebellar events, whereas the preva-
lence of headache in patients with brainstem events
was not higher than other patient groups.
• In addition, median blood pressure values less than
120/70mmHg was associated with increased preva-
lence of headache at stroke onset.
There was no association between headache at
stroke onset and presumed aetiology of the event or
22 Progress in Neurology and Psychiatry
Headache attributed to ischaemic stroke (IHS 6.1.1) is
described in IHS classification as a new headache that
develops simultaneously with, or in close temporal
relationship with, signs or other evidence of ischaemic
stroke accompanied by neuroimaging confirmation of
ischaemic infarction.
Headache attributed to TIA (IHS 6.1.2) is described
in IHS classification as a new headache that develops
simultaneously with onset of focal neurological deficit
lasting less than 24 hours and resolving within 24
hours. Headaches are more common in TIAs occur-
ring in basilar than carotid territory.
The dif ferential diagnosis between TIA with
headache and an attack of migraine with aura may be
particularly difficult. The mode of onset is crucial; the
focal deficit is typically sudden in TIA and more fre-
quently progressive in migranous aura. Furthermore,
positive phenomena, eg scintillating scotoma, are far
more common in migranous aura, whereas negative
phenomena are more common in TIA.
Clinical characteristics
Sentinel headache, which usually occurs prior to sub-
arachnoid haemorrhage, is not an uncommon symp-
tom of cerebral ischaemia. It occurs in 10-43 per cent
of patients with ischaemic stroke and is more common
in cardioembolic infarcts (22 per cent) than in TIAs,
lacunar infarcts or thrombotic infarcts.13 In cardioem-
bolic infarcts, sentinel headache is unilateral, of sud-
den onset and can precede the onset of neurological
deficit by between 24 and 72 hours.
Onset of headache in ischaemic stroke is equally
likely to be abrupt or gradual in onset.1 It is usually
unilateral, focal and of mild to moderate severity; how-
ever, a significant proportion of patients may have inca-
pacitating pain.8
In contrast to headache in subarachnoid haemor-
rhage, which is usually explosive and of abrupt onset,
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 Review
Headache in ischaemic stroke

Artery involved in infarct Characteristics of Key points

Posterior cerebral artery
Vertebral artery
Basilar artery
Middle cerebral artery
Anterior cerebral artery
Table 3. Characteristics of headache according to the type
of artery involved in the infarct
headache
• Headache occurs in nearly one-quarter of patients with acute
Frontal and lateralised
ischaemic stroke
Pain over eyes, nose and cheek,
• Unilateral headache is often ipsilateral to ischaemic stroke lesion
or occipital, lateralised
• Headache is more common in infarcts involving the posterior
Occipital, lateralised, associated
circulation
with neck stiffness
• There is a strong association of headache at stroke onset with
Steady pain behind
younger age and history of migraine
corresponding eye
• The severity of headache is not related to size of ischaemic
Uni- or bifrontal
stroke lesion
• There is no association between headache and stroke aetiology
or outcome

the quality of pain in ischaemic cerebrovascular dis-
ease varies widely. The pain is most often non-specific
in character and has been reported as either throb-
bing or continuous and non-throbbing.1,8 It is rarely
felt as stabbing, pulsatile or having clinical features
similar to intracranial hypertension. It is frequently
associated with nausea (44 per cent), vomiting (23 per
cent), and photophobia and phonophobia.
The headache is usually made worse by bending,
straining or jarring the head. Transient worsening can
also occur with the use of sublingual glycer yl trini-
trate. Digital compression of the superficial temporal
artery on the the headache side of the head temporar-
ily eases the discomfort. The duration of the headache
is longest in cardioembolic and thrombotic infarcts,
shortest in TIAs and of medium duration in lacunar
infarction. 14 The average duration of headache in
ischaemic stroke is 25 hours compared with 65 hours
in haemorrhagic stroke.14
Headaches are lateralised in 46 per cent of
patients, being ipsilateral to the stroke in 68 per cent
of these patients and contralateral in 32 per cent.15
The characteristics of headache also vary according
the the arter y involved in the infarct, as shown in
Table 3.
The severity of headache is not related to the size
of the infarction, but the intensity of pain is felt to be
more severe when located occipitally than when
located frontally. 8 Stroke-related headache is not
related to overall stroke outcome.8
Conclusion
Headache is a common symptom in ischaemic stroke,
but is often overlooked by the clinician as a result of con-
centrating on clinical signs and further management of
the patient. A basic knowledge of headache in ischaemic
stroke is essential during the assessment of stroke
patients. Further research is needed into the underly-
ing aetiology and clinical significance of headache in
stroke and how it relates to other clinical factors.
Dr Raghunathan is a Specialist Registrar, Dr Richard
is an Associate Specialist and Dr Khanna is a
Consultant Geriatrician and Lead Clinician in Stroke
Care, all in the Department of Adult Medicine at
Nevill Hall Hospital, Abergavenny
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