Headache Prevalence in Stroke
Approximately 25-38% of all strokes present with headache at onset, with significant variation based on stroke type: ischemic strokes present with headache in 23-32% of cases, while hemorrhagic strokes present with headache in 58-100% of cases. 1, 2
Stroke Type-Specific Prevalence
Ischemic Stroke
- Overall ischemic stroke headache prevalence ranges from 23-34% across multiple studies 2, 3, 4, 5
- Thrombotic infarcts: 41% present with headache 2
- Cardioembolic infarcts: 39% present with headache 2
- Lacunar infarcts: 23-26% present with headache (significantly lower than other ischemic subtypes) 2
- Transient ischemic attacks (TIA): 26-36% present with headache 2, 5
Hemorrhagic Stroke
- Hemorrhagic strokes have substantially higher headache prevalence at 58-100% 2, 6
- Subarachnoid hemorrhage: 100% in some series, with 74-80% describing "worst headache of my life" 7, 8, 2, 6
- Intraparenchymal hemorrhage: 58-64.5% present with headache 2
Anatomic Distribution Patterns
Vascular Territory
- Posterior circulation strokes have the highest headache prevalence at 59%, compared to carotid territory strokes at 26% 2, 3
- Cortical strokes: 56.5% present with headache 2
- Subcortical strokes: 26.5% present with headache 2
Clinical Characteristics by Stroke Type
Ischemic Stroke Headache Features
- Typically mild to moderate intensity (74% of cases) 2, 5
- Focal/unilateral in 74% of ischemic cases 2
- Mean duration: 25 ± 28 hours 2
- Usually bilateral tension-type pattern without associated nausea, vomiting, photophobia, or phonophobia 5
Hemorrhagic Stroke Headache Features
- Incapacitating intensity in 70% of hemorrhagic cases 2
- Diffuse in 52% of hemorrhagic cases 2
- Mean duration: 64.5 ± 36.5 hours (significantly longer than ischemic) 2
- Subarachnoid hemorrhage characterized by sudden onset with nausea, vomiting, neck pain, photophobia, and potential loss of consciousness 6
Predictive Factors for Headache Presence
Patient Demographics
- Younger age significantly associated with headache presence (mean age 62 vs 67 years in non-headache patients) 2, 5
- History of pre-existing headache disorders: 40.5% in headache group vs 23.5% in non-headache group 2
- Pre-existing migraine increases odds of stroke-related headache by 27.4-fold 3
- Pre-existing tension-type headache increases odds by 7.6-fold 3
Clinical Factors
- Lower NIHSS scores (less severe strokes) associated with higher headache prevalence 3, 4
- Fever increases odds of headache by 3.75-fold 3
- Small vessel disease decreases odds of headache by 0.51-fold 3
- Chronic hypertension associated with lower headache frequency 3
Pediatric Stroke Considerations
- Headache is the most common presenting symptom in pediatric stroke at 56%, followed by vomiting (36%) and focal weakness (35%) 1
- Pediatric stroke incidence: 1.5-13 per 100,000 children per year 1
- Common stroke mimics in children include migraine (38%), seizures with postictal paralysis (15%), and Bell's palsy (10%) 1
Critical Clinical Pearls
Sentinel Headaches
- Sentinel headaches occur in 10-43% of patients with aneurysmal SAH within 2-8 weeks before major rupture 7
- Dismissing warning headaches increases odds of early rebleeding 10-fold 7
Diagnostic Pitfalls
- Misdiagnosis of aneurysmal SAH occurs in up to 12% of cases, with failure to obtain neuroimaging being the most common error 7
- Only 62.5% of headaches at stroke onset fulfill ICHD-III diagnostic criteria, leading to underdiagnosis 4
- Headache is often overlooked in stroke patients due to focus on neurologic deficits and communication difficulties 4
Key Distinguishing Features
- The suddenness of onset, not severity, is the characteristic feature of subarachnoid hemorrhage headache 6
- Headache is the only symptom in approximately one-third of subarachnoid hemorrhage patients 6
- Associated focal neurological deficits or cranial nerve palsies require immediate neuroimaging and should not be dismissed 7