Are steroids effective for treating headache due to stroke?

Steroids Are Not Recommended for Headache Due to Stroke

Corticosteroids are not recommended for the treatment of headache due to stroke as they lack evidence of efficacy and may increase risk of complications. 1

Evidence Against Steroid Use in Stroke-Related Headache

The 2013 American Heart Association/American Stroke Association guidelines explicitly state that "because of lack of evidence of efficacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) are not recommended for treatment of cerebral edema and increased ICP complicating ischemic stroke" (Class III; Level of Evidence A). 1

This recommendation is further supported by:

• European Stroke Organisation guidelines which found no benefit of dexamethasone on mortality or functional outcomes in patients with intracerebral hemorrhage 1
• A randomized controlled trial showing high-dose dexamethasone was ineffective in ischemic stroke 2

Understanding Headache in Stroke

Headache occurs in approximately 27% of stroke patients, with higher prevalence in:

• 50% of patients with intracerebral hemorrhage
• 26% of patients with cerebral infarction
• 15% of patients with lacunar infarction 3

Headache is more common in posterior circulation strokes than anterior circulation strokes. When unilateral, the headache is typically ipsilateral to the stroke lesion in most cases. 3

Appropriate Management of Stroke-Related Complications

For patients with stroke experiencing headache, management should focus on:

1. Treating the underlying stroke according to established guidelines

2. Managing cerebral edema when present through:

   • Early mobilization and adequate hydration 1
   • Decompressive surgery for malignant edema when indicated 1
   • Placement of ventricular drain for acute hydrocephalus 1

3. Pain management options that may be considered:

   • Standard analgesics (acetaminophen/paracetamol)
   • For central post-stroke pain (if developed later):
     • Amitriptyline or lamotrigine as first-line treatments 1
     • Pregabalin, gabapentin, carbamazepine, or phenytoin as second-line treatments 1

Pitfalls to Avoid

1. Do not use corticosteroids for cerebral edema or headache in stroke patients as they:

   • Lack evidence of efficacy
   • May increase risk of infectious complications
   • Could potentially worsen outcomes in some patients 1

2. Do not confuse with other headache types where steroids might be beneficial:

   • Status migrainosus
   • Medication overuse headache
   • Giant cell arteritis (which requires immediate high-dose glucocorticoids) 1, 4, 5

Monitoring and Follow-up

• Regular assessment of pain using standardized scales
• Monitoring for development of central post-stroke pain syndrome
• Vigilance for other stroke complications that may contribute to headache

In conclusion, while steroids may be beneficial in certain headache disorders, they have no established role in the management of headache due to stroke and should be avoided due to potential harm.