What blood work would you order for a patient with recurrent headaches and a history of hemorrhagic stroke?

Blood Work Recommendations for Patients with Recurrent Headaches and History of Hemorrhagic Stroke

For patients with recurrent headaches and a history of hemorrhagic stroke, a comprehensive blood work panel should include complete blood count, coagulation studies, basic metabolic panel, HbA1c, and lipid profile to assess stroke risk factors and guide secondary prevention strategies.

Rationale for Blood Work Selection

The American Heart Association/American Stroke Association guidelines specifically recommend several key blood tests for patients with cerebrovascular disease that are particularly relevant for those with hemorrhagic stroke history and recurrent headaches:

Essential Blood Tests

1. Complete Blood Count (CBC)

   • Evaluates for anemia, thrombocytopenia, or other hematologic abnormalities that could contribute to bleeding risk or headache 1
   • Platelet count is especially important in patients with prior hemorrhagic stroke to assess bleeding risk

2. Coagulation Studies

   • Prothrombin time (PT), partial thromboplastin time (PTT), and INR 1
   • Critical for patients with history of hemorrhagic stroke to identify coagulopathies
   • Essential if patient is on or being considered for antithrombotic therapy

3. Basic Metabolic Panel

   • Includes electrolytes, glucose, and creatinine 1
   • Abnormalities may contribute to headaches and affect stroke risk

4. Hemoglobin A1c (HbA1c)

   • Recommended to assess glycemic control 1
   • Diabetes is a significant risk factor for both recurrent stroke and headaches

5. Lipid Profile

   • Fasting or non-fasting lipid panel 1
   • Important for overall vascular risk assessment and secondary prevention

Additional Targeted Tests Based on Clinical Suspicion

For patients with recurrent headaches and hemorrhagic stroke history, consider these additional tests if clinically indicated:

• Inflammatory Markers

  • ESR and CRP if vasculitis or inflammatory conditions are suspected 1
  • Particularly relevant if headache characteristics suggest inflammatory etiology

• Hypercoagulability Testing

  • For patients with cryptogenic stroke or suspected hypercoagulable state 1
  • May include protein C, protein S, antithrombin III, factor V Leiden, etc.

• Toxicology Screen

  • If substance use is suspected as contributing to headaches or prior stroke 1
  • Particularly important for stimulants that can cause both headaches and hemorrhage

Clinical Considerations

Timing of Laboratory Assessment

• Blood tests should be completed within 48 hours of presentation for acute symptoms 1
• For patients with stable recurrent headaches, testing can be done during outpatient evaluation

Special Considerations for Hemorrhagic Stroke Patients

Patients with hemorrhagic stroke history require particular attention to:

• Coagulation Parameters: More stringent monitoring if on anticoagulants or antiplatelets
• Blood Pressure Control: Hypertension is a major risk factor for both recurrent hemorrhagic stroke and headaches 1
• Medication Effects: Some preventive medications for headache may affect stroke risk

Headache Characteristics and Additional Testing

The pattern of headaches may guide additional testing:

• Sudden severe headaches may warrant more urgent evaluation including imaging
• Gradual onset, tension-type headaches after stroke are common (affecting up to 23% of post-stroke patients) 2
• Headaches are more common following hemorrhagic stroke (64.5%) than ischemic stroke (32%) 3

Common Pitfalls to Avoid

1. Overlooking medication overuse: About one-third of patients with persistent post-stroke headaches develop medication overuse headache 4

2. Focusing only on stroke prevention: While secondary stroke prevention is critical, addressing the headaches themselves is important for quality of life

3. Missing sleep disorders: Lack of sleep is associated with persistent post-stroke headaches (29.1% of cases) 4

4. Ignoring cerebellar involvement: Cerebellar infarcts are associated with higher rates of persistent headache 4

By systematically evaluating these laboratory parameters, clinicians can better assess both the risk of recurrent hemorrhagic stroke and identify potential contributors to the patient's headaches, leading to more effective management strategies.