From the Guidelines
Opioids are not the preferred treatment for ischemic stroke-related headache pain due to their potential to mask neurological symptoms and increase intracranial pressure. The most recent and highest quality study, 1, published in 2023, suggests that treatment of headache in spontaneous intracranial hypotension (SIH) should focus primarily on management of the underlying cause, with symptomatic management using paracetamol and/or non-steroidal anti-inflammatory drugs. While opioid medication may be required to provide adequate pain relief in some cases, it should be avoided in routine long-term management of headache.
In the context of ischemic stroke, the Canadian Stroke Best Practice Recommendations, 1, suggest that patients with persistent Central Post Stroke Pain (CPSP) should receive a trial of low-dose, centrally acting analgesics, with anticonvulsants, tricyclic antidepressants, or SNRIs as first- or second-line treatments. Opioids or tramadol may be considered for patients resistant to first- and second-line treatments, but with caution due to the risk of physical dependency.
Key considerations in managing ischemic stroke-related headache pain include:
- Identifying and treating the underlying cause of pain
- Maintaining the ability to monitor neurological status accurately
- Avoiding medications that may worsen outcomes, such as opioids, which can cause respiratory depression, alter mental status, and increase intracranial pressure
- Consulting with a neurologist or pain specialist if pain persists despite initial treatment.
Given the potential risks and limitations of opioid use in this context, a more cautious approach is recommended, prioritizing non-opioid analgesics and interdisciplinary management.
From the Research
Opioids in Ischemic Stroke-Related Headache Pain
- The use of opioids in treating ischemic stroke-related headache pain is still debated, with limited studies available to support their efficacy 2.
- A systematic review and meta-analysis found that seven out of eight included studies showed an overall slight analgesic effect of opioids, but the results were inconclusive due to the small number of studies and patients 2.
- Headaches attributed to ischemic strokes are frequent, with a prevalence varying between 7.4% and 34% of cases, and are often overlooked and underdiagnosed 3.
- The most common pattern of headache attributed to ischemic stroke is a mild to moderate bilateral pain, not associated with nausea, vomiting, photophobia, or phonophobia 3.
- There are no clinical trials on pain management or prophylactic treatment of persistent headache attributed to ischemic stroke, highlighting the need for further research 3.
- A case study suggested that understanding the exact pathophysiology and recognition of clinical and radiological predictors can help provide good management and open scope for prophylactic approaches for headache attributed to ischemic stroke 4.
- The use of opioid antagonists, such as naloxone and nalmefene, has been investigated in the treatment of ischemic stroke, with some studies showing promising results 5.
- The brain opioid system has been found to have a neuroprotective role in stroke injury, and targeting opioid receptors may provide a viable target for the pharmacological treatment of stroke 6.