Headache Associated With Transient Ischemic Attacks

Sixty (29%) of 205 consecutive patients with transient ischemic attacks registered in a hospital stroke data base had headache within 72 hours of onset. Headache was significantly more common in nonsmokers (odds ratio = 2.8; 95% confidence interval = 6.7 to 1.2). Headache was infrequent in patients with amaurosis fugax, and was not significantly associated with any other particular clinical presentation of transient ischemic attack. Headache was more common in vertebrobasilar (33%) than in carotid distribution (24%) episodes, and was not rare in transient ischemic attacks presenting as lacunar syndromes (29%). Headache was less frequent in patients whose computerized tomograms showed an infarct appropriate to the symptoms (odds ratio = 0.2; 95% confidence interval = 0.02 to 1.4). A diffuse headache was more common in patients with lacunar events than in patients with cortical attacks (odds ratio = 3.0; 95% confidence interval = 13 to 0.07). No other association was found between headache location and the presumed involved vascular territory. Headache in patients with transient ischemic attacks is poorly related/explained by the clinical characteristics of the ischemic event.     

Headache in acute cerebrovascular disease: a prospective clinical study in 240 patients

To evaluate the clinical features of headache in stroke, a prospective study was carried out in 240 consecutive patients with acute stroke who had intact expressive function. Headache occurred in 38%: 32% of 195 patients with ischemic stroke and 64.5% of 45 patients with hemorrhagic stroke ( p < 0.0001). Headache patients were younger (mean age 62 ± 15 vs 67 ± 11.5 years) than non-headache patients ( p < 0.01). A history of previous vascular or tension-type headache was found in 40.5% of the headache group, but in only 23.5% of the non-headache group ( p < 0.01). In ischemic stroke, headache was observed in 41% of thrombotic infarcts, in 39% of cardioembolic infarcts, in 23% of lacunar infarcts and in 26% of TIA. Headache was significantly more common in thrombotic than lacunar infarcts ( p < 0.05). In hemorrhagic stroke, headache was observed in all subarachnoid hemorrhages and in 58% of intraparenchymal hemorrhages. In ischemic stroke, the mean duration of the headache was 25 ± 28 h and in hemorrhagic stroke 64.5 ± 36.5 h ( p < 0.00001). In ischemic stroke the headache was focal in 74% and mild or moderate in intensity in 74%. In hemorrhagic stroke, it was diffuse in 52% and the pain intensity was incapacitating in 70%. Headache was more common in vertebrobasilar stroke (59%), in comparison with carotid stroke (26%) or stroke of unclear vascular topography (33%) (p < 0.00001). Fifty-six and a half percent of patients with cortical stroke had headaches, as opposed to only 26.5% of patients with subcortical stroke ( p < 0.005). Ten percent of the patients presented with sentinel headache.     

Headache associated with acute ischemic stroke

Headache occurs frequently in acute ischemic stroke, but its frequency varies widely among different studies. We have prospectively studied headache features in patients with first-ever ischemic acute stroke and assessed the relationship between headache, stroke location, and etiology. The study included consecutive patients admitted to our Stroke Unit for a first-ever ischemic acute stroke. The study included 154 consecutive patients with ischemic stroke, and 54 of these (35.1%) had headache during stroke onset. Twelve patients (22.2%) with headache during stroke had history of headache; no patients without headache had history of headache. Headache was present in 25.8% (32/124) of the patients with anterior circulation stroke and in 73.3% (22/30) of the patients with posterior circulation stroke (p=0.001). Large artery disease was more frequent with than without headache (40.7% versus 14.0%, p=0.04). Headache was present in more than one-third of the patients with ischemic stroke. All patients with positive history for headache had headache during stroke onset. The cephalic pain was much more common among patients with infarcts in the posterior circulation than in patients in whom the anterior circulation was involved. Headache was more common when the cause of stroke was large artery disease. Received: 5 January 2001 / Accepted in revised form: 6 April 2001     

Association between migraine and headache attributed to stroke: a case-control study

Background.— Several studies were carried out to investigate the occurrence of headache attributed to acute stroke in patients with a lifetime history of migraine. Methods.— In a case–control series of 96 acute stroke patients with a lifetime history of migraine (M+) and 96 stroke patients without (M?), ischemic stroke patients only, without secondary infarction, were selected. The headache attributed to acute ischemic stroke was then analyzed. Results.— (M+) patients complained of headache more often than (M?) patients (P < .0001), mainly in the 24 hours before stroke onset (P < .0001). Migraine‐like features of headache were recognized in a greater proportion of cases in the (M+) patient group with ischemic stroke (P < .018). A preferential brainstem location of ischemic stroke in (M+) patients emerged compared with (M?) patients (P = .014). Discussion.— The high prevalence of headache attributed to stroke in (M+) patients, in a relevant proportion of cases presenting as a sentinel headache, suggests that cerebral ischemia lowers the threshold for head pain more easily in these “susceptible” patients. The most frequent involvement of the brainstem in (M+) patients with ischemic infarction concurs with recent reports that emphasized a greater headache frequency when cerebral infarctions are localized in this structure or deep brain gray matter.     

A history of migraine is not a risk factor to develop an ischemic stroke in the elderly

OBJECTIVE: To assess the prevalence of migraine in elderly patients hospitalized with ischemic stroke compared with vascular and nonvascular control groups. BACKGROUND: Migraine is a disease with a presumed vascular mechanism. While migraine is a common complaint of young victims of ischemic stroke, it is unclear whether a current or past history of migraine constitutes a risk factor for developing an ischemic stroke in the elderly. METHODS: We obtained current and past headache history from 100 consecutive patients hospitalized with ischemic stroke (aged 60 years or older) and compared the results with 100 patients hospitalized due to acute myocardial infarction and 100 hospitalized patients with no vascular disease. RESULTS: The sex and the age of the patients did not differ among the groups. The lifetime prevalence of migraine (8% of the patients with ischemic stroke, 8% of the nonvascular controls, and 15% of the patients with acute myocardial infarction) or of all types of headaches (27%, 30%, and 15%, respectively), did not differ significantly between the groups. CONCLUSIONS: Based on the reported history, elderly migraineurs are not at increased risk to develop ischemic stroke.     

Comorbidity of headaches and depression in the elderly.

The comorbidity of headache and depression is rarely studied in the elderly. Confounders were seldom controlled in previous studies. From August 1993 to March 1994, we conducted a door-to-door survey to investigate the relationship of headache and depression in a Chinese elderly population (age > or = 65 years old) in two townships of Kinmen, Taiwan. A total of 1421 participants (71%) out of 2003 eligible citizens completed five measurements: a structured headache interview, Geriatric Depression Scale-short form (GDS-S), a survey of chronic medical illness. Cognitive Abilities Screening Instrument and an evaluation of activities of daily living. Headache diagnoses were made according to the criteria of the International Headache Society (IHS), 1988. Depression was defined as a GDS-S score > or = 8. After adjustment for confounding, subjects with more frequent headaches, more severe headaches, diagnoses of IHS migraine or chronic tension-type headaches in the past year, or a lifetime history of any headache including migraine were more likely to be depressed. In addition, the most relevant headache-related predictors of depression were the presence of any reported lifetime headache (odds ratio (OR) = 1.8, P < 0.01) and headache frequency > or = 7 days/month in the past year (OR = 2.0, P = 0.01). This study provided evidence that headache is independently associated with depression in the elderly. A high comorbidity of depression was found in the elderly with IHS migraine or chronic tension-type headaches. Not only the headache profile in the past year but also that in their lifetime was important in predicting current depression in the elderly. 1     

Diagnostic criteria for CADASIL in the International Classification of Headache Disorders (ICHD-II): are they appropriate?

We reviewed the characteristics of headache in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), to verify the appropriateness of the International Classification of Headache Disorders, second edition (ICHD-II) criteria. Available data were found through Medline/PubMed using the keyword “cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)”. The search was restricted to studies published in English in the years between 1993 and 2008. We excluded studies that did not report original data on CADASIL and information regarding the presence of headache. We found 34 studies reporting data on 749 patients overall; 387 (51.7%) patients had headache. According to the authors’ definition, 356 (92%) patients were reported as having migraine and 31 (8%) as having headache. Of the 356 patients who were defined as migraineurs, 125 (35.1%) had migraine with aura, 7 (2%) migraine without aura, 156 (43.8%) unspecified migraine and 68 (19.1%) had more than one type of migraine. Among the 31 patients reported as suffering from headache, the headache was not further detailed in 18 (58.1%) patients; it was defined as chronic in 6 (19.3%), as resembling migraine with aura in 4 (12.9%), as resembling migraine without aura in 2 (6.5%) and as tension type in 1 (3.2%) patient. In patients with CADASIL, the headache was usually referred to as migraine and mostly as migraine with aura. However, this referral is formally incorrect since the diagnostic criteria for any type of migraine in the ICHD-II require that the disturbance is not attributed to another disorder. For this reason, we suggest updating the ICHD-II in relation to CADASIL. Our suggestion is to insert a new category referred to as Headache attributed to genetic disorder including Headache attributed to CADASIL.     

Commentary on Headache Currents Articles by Alhazzani and Goddeau

Headache is a symptom of cerebrovascular disease, particularly the hemorrhagic type. Also, certain headache types, notably migraine with aura, predispose individuals to ischemic and perhaps hemorrhagic stroke. The relationship between migraine and cerebrovascular disease can be causal, coincidental or co‐morbid.     

The association between migraine and juvenile stroke: a case-control study

BACKGROUND: Several studies suggest an association between migraine and juvenile stroke. Because of some shortcomings, we designed another case-control study of a homogenous group of patients with juvenile cerebral ischemia. This study is part of a larger German epidemiological research project on the association of migraine with cerebrovascular disease. METHODS: We enrolled 160 consecutive patients under the age of 46 years with first-ever ischemic stroke or transient ischemic attack and 160 strictly sex- and age-matched controls. Patients suffering from arterial dissection, brain hemorrhage, cranial sinus thrombosis, lacunar stroke, or from migrainous infarction were excluded. Migraine was diagnosed according to the criteria of the International Headache Society by the same 2 independent interviewers. For analyzing the data, nonparametric statistical methods including odds ratio and 95% confidence interval were used. RESULTS: Migraine was a significant risk factor for juvenile stroke for the total sample with an odds ratio of 2.11 (confidence interval, 1.16 to 3.82). The odds ratio was even higher in the subgroup under the age of 35 (3.26) and in the female subgroup (2.68). We found migraine to be independent from other vascular risk factors, from etiology, and from the territory of stroke. CONCLUSION: We can confirm the findings of previous studies showing a significant association between migraine and juvenile stroke in women. Furthermore, our data suggest migraine to be an even more significant risk factor for patients under the age of 35 and to be independent from other vascular risk factors.     

Headache associated with transient or permanent cerebrovascular disease

Headache is a common symptom in stroke, however the frequency, location, duration and other characteristics of the patients who developed headache during stroke are difficult to define. We studied headache characteristics in patients with first-ever acute stroke (hemorrhagic or ischemic) or transient ischemic attack (TIA) and assessed the relationship between headache, stroke location, and etiology. The study included 104 consecutive patients (mean age 55.8±0.8 years; range, 40–70 years) admitted with acute stroke. Eleven patients had TIA, 70 ischemic stroke, and 23 hemorrhagic stroke. Headache was reported in 37 patients (35.6%) and was more common in hemorrhagic stroke compared to ischemic stroke or TIA (p<0.05). Headache was present in 26.8% of the patients with anterior circulation stroke and in 62.5% of the patients with posterior circulation stroke (p=0.006). No relationship was found between the size of the lesion detected by computed tomography and the presence of headache. Received: 18 February 2002, Accepted in revised form: 19 June 2002 Correspondence to S. M. Hamdy     

Duplex Sonography of Vertebral Arteries for Evaluation of Patients with Acute Vertigo

We evaluated the role of vertebral artery extracranial color-coded duplex sonography (VAECCS) in predicting vertebrobasilar stroke in consecutive patients presenting to the emergency department with vertigo of suspected ischemic origin. The final diagnosis was established by a panel of experts consisting of an emergency physician, a neurologist, and an otoneurologist. Vertebrobasilar stroke was diagnosed when an acute brain ischemic lesion congruent with symptoms was detected by neuroimaging during the index visit or a stroke was diagnosed within a 3-mo period after emergency department presentation. Among 126 patients, 28 (22%) were diagnosed with vertebrobasilar stroke. Fifteen (75%) of 20 patients with abnormal VAECCS results and 13 (12%) of 106 with normal VAECCS results had a final diagnosis of vertebrobasilar stroke. The sensitivity and specificity of VAECCS were 53.6% and 94.9%, respectively. Detecting an abnormal flow pattern at VAECCS significantly increased the risk of vertebrobasilar stroke (odds ratio?=?21.5). The flow patterns most frequently related to vertebrobasilar stroke were absence of flow and high resistance pattern velocity (odds ratio?=?9.3 and 22.7, respectively). VAECCS predicts vertebrobasilar stroke and could be a useful bedside screening tool in patients with vertigo.     

Postangiography Headache

In order to study the frequency and characteristics of post-angiography headache, we interviewed 45 consecutive patients (mean age ± SD= 57 ± 15 years; M/F=15/30) who underwent transfemoral cerebral angiography for: ischemic cerebrovascular disease (n=33); suspected arteriovenous malformations (n=4; one confirmed); suspected cerebral aneurysm (n=5; two confirmed); and arterial dissection (n=3; one confirmed and one was a follow-up study of a previously demonstrated dissection). Postangiography headache developed in 15 (33%) patients, 125 ± 99 min after the completion of the study. It was unilateral in nine (60%) patients, homolateral to the usual side of migraine headache in two of three migraineurs, and pulsating in six (40%). Nausea, vomiting, photophobia, and phonophobia accompanied postangiography headache in 20%, 7%, 33%, and 20% respectively. Postangiography headache fulfilled the International Headache Society criteria for migraine without aura (except for the number of attacks) in 27% of patients. Patients with and those without postangiography headache were comparable in mean age, sex, and indication for angiography. Fifty-three percent (8/15) of patients with postangiography headache and 23% (7/30) of the non postangiography headache group reported prior recurrent headaches (P =0.047, likelihood ratio chi-square). Postangiography headache has the characteristics of delayed arterial pain which may be related to a catheter-induced or contrast dye-induced release of vasoactive substances, notably nitric oxide and serotonin.     

Headache and ischemic stroke

Migraine is a common neurological condition affecting yearly 1%–10% of all men and 3%–20% of all women. Focal neurological symptoms (auras), most commonly visual and sensory, occur in 4% of migraine attacks. Migraine with and without aura seems to be associated with an increased stroke risk. Migraine with aura may mimic transient ischemic attacks and may induce stroke (migrainous stroke). Headache is also a common symptom during ischemic stroke In this review, we present the evidence about each of these circumstances to better understand the relationship between headache, especially migraine, and ischemic stroke. Received: 27 September 2001 / Accepted in revised form: 27 December 2001     

Medication overuse headache: predictors and rates of relapse in migraine patients with low medical needs. A 1-year prospective study

The aim of this study was to evaluate the rates and predictors of relapse, after successful drug withdrawal, in migraine patients with medication overuse headache (MOH) and low medical needs. The study population, study design, inclusion criteria and short-term effectiveness of the medication withdrawal strategies have been described elsewhere (Rossi et al., Cephalalgia 2006; 26:1097). Relapsers were defined as those patients fulfilling, at follow-up, the new International Classification of Headache Disorders, 2nd edn, appendix criteria for MOH. Complete datasets were available for 83 patients. At 1 year's follow up, the relapse rate was 20.5%. Univariate analysis showed that patients who relapsed had a longer duration of migraine with more than eight headache days/month, a longer duration of drug overuse, had tried a greater number of preventive treatments in the past, had a lower reduction of headache frequency after withdrawal, and had previously consulted a greater number of specialists. Binary logistic regression analysis was performed, and three variables emerged as significant predictors of relapse: duration of migraine with more than eight headache days/month [odds ratio (OR) 1.57, P = 0.01], a higher frequency of migraine after drug withdrawal (OR 1.48, P = 0.04) and a greater number of previous preventive treatments (OR 1.54, P = 0.01). In patients with migraine plus MOH and low medical needs, relapse seems to depend on a greater severity of baseline migraine.     

Thunderclap headache attributed to reversible cerebral vasoconstriction: view and review

Thunderclap headache attributed to reversible cerebral vasoconstriction (THARCV) is a syndrome observed in a number of reported cases. In this article we reviewed this new headache entity (idiopathic form) using the clinical-radiological findings of 25 reported patients. In this series of patients 72% were women, the mean age at the onset of first headache episode was 39.4 +/- 2.3 years. In addition to the sine qua non condition of being abrupt and severe (thunderclap) at the onset, the headache was usually described as being explosive, excruciating, or crushing. The feature of pulsatility, accompanied or not by nausea was described by 80% of the patients. Forty percent of the cases manifested vomiting and 24% photophobia. Usually the headache was generalized, and in three cases it was unilateral at least at the onset. In 21 of 25 patients (84%) there was at least one recurrence or a sudden increase in the intensity of the headache. A past history of migraine was present in 52% of the patients. Precipitating factors were identified in 56% of the patients. Sexual intercourse was described by six patients. Of the 25 patients with THARCV syndrome studied, 12 (48%) developed focal neurological signs, transitory ischemic attack (n = 1), or ischemic stroke (n = 11, 44%), and two (8%) of them manifested seizures. The THARCV syndrome is a neurological disturbance perhaps more frequent than expected, preferentially affecting middle aged female migraineurs, and having an unpredictable prognosis, either showing a benign course or leading to stroke.     

Migraine Diagnosis and Clinical Symptomatology

Migraine is a very common phenomenon. Eighteen percent of women in this country and 6% of men have migraine. The old classification for headaches and diagnostic criteria were published in 1962, more than a quarter of a century ago. In 1988, the International Headache Society published a new classification and diagnostic criteria for all headache disorders, cranial neuralgias, and facial pain. The International Headache Society classification divides migraine, as it had been divided in the past, into two major categories: migraine without aura (formerly called common migraine) and migraine with aura (formerly called classical migraine). These criteria are rather complex and simpler criteria are proposed for clinical practice. The typical patient with migraine is a woman whose headaches began in adolescence or young adult life. There usually is a family history of migraine. Migraine is almost always more than just a headache. Virtually anything in the external environment and many things in the internal milieu may provoke migraine in a susceptible individual. There are many potential manifestations of the aura of migraine, but 90% are visual phenomena. Migraine in children is a little different than in adults. When the onset is below the age of puberty, the ratio of females to males is equal, but after puberty there is a striking predominance of women over men in a ratio of 3:1. Whenever the history of migraine is not typical or if something unexpected is found on examination, imaging studies are warranted.     

脑梗死患者脑微量出血的发生及危险因素分析

目的探讨脑梗死患者脑微量出血(CMB)的发生情况及其危险因素。方法收集1～6个月内脑梗死患者,详细记录临床资料,采用临床资料盲法对CMB、腔隙性梗死及脑白质病变(WML)进行评估。采用Logistic回归分析CMB发生的独立危险因素。结果共收集了636例患者。250例(39.3%)存在CMB。≤50岁、50～65岁及>65岁组CMB发生率依次为27.2%、38.1%和47.6%(P<0.05)。腔隙性梗死数目越多,CMB发生率越高(P<0.05)。在无WML、轻度、中度和重度WML患者中CMB的发生率依次为21.9%、33.8%、46.9%和63.1%,组间比较均有显著性差异(P<0.05)。Logistic回归分析显示,高血压病史(OR=1.523,95%CI 1.019～2.276)、WML程度(OR=1.535,95%CI 1.258～1.874)和腔隙性梗死程度(OR=1.517,95%CI 1.087～2.118)是发生CMB的独立危险因素。结论脑梗死患者中CMB发生率较高。年龄越大、腔隙性梗死和WML程度越严重,CMB的发生率越高。高血压病史、WML和腔隙性梗死程度是脑梗死患者发生CMB的独立危险因素。     

Migraine is associated with livedo reticularis: a prospective study

OBJECTIVE: To investigate the relationship of livedo reticularis, an ischemic dermatopathy, and migraine, an ischemic stroke risk factor. BACKGROUND: Livedo reticularis refers to the reddish-blue reticular mottling of the skin resulting from narrowing of small and medium arteries at the dermis-subcutis border. A subset of patients with livedo reticularis develop stroke in the absence of other vascular risk factors, which has been termed Sneddon syndrome. We undertook this prospective study in a non-neurology clinic to delineate further the relationship of livedo reticularis and migraine. METHODS: Patients in a general dermatology clinic were interviewed for vascular risk factors and history of migraine in accordance with the International Headache Society (IHS) criteria. A dermatologist, not familiar with the interview, recorded the primary dermatological diagnosis and the presence or absence of livedo reticularis on examination. RESULTS: Two hundred eighty-one consecutive patients (184 women and 97 men; average age, 52 years) were interviewed and examined. Seventy-five (27%) had migraine (IHS codes 1.1, 1.2) and an additional 18 (6%) had atypical migraine (IHS 1.7). Livedo reticularis was noted in 46 patients (16%), with the frequency higher in women than men (42 [23%] of 184 versus 4 [4%] of 97; P <.0001). The frequency of livedo reticularis in patients with migraine was higher than in those without migraine (24 [26%] of 93 versus 22 [12%] of 188; P =.002), and higher in female than male migraineurs (23 [32%] of 72 versus 1 [5%] of 21; P =.012). In logistic regression analysis of the women, migraine was associated with livedo reticularis (odds ratio [OR], 2.3; confidence interval [CI], 1.08 to 4.71), as well as with stroke (OR, 4.0; CI, 0.87 to 18.21), coronary artery disease (OR, 3.5; CI, 1.16 to 10.33), and deep venous thrombosis (OR, 3.2; CI, 0.98 to 10.32). CONCLUSIONS: In women, migraine is associated with stroke, coronary artery disease, deep venous thrombosis, as well as livedo reticularis, a dermatopathy which has been pathologically linked to cerebral vasculopathy. Whether migraineurs with livedo reticularis compose a subset at higher risk of thrombosis, including stroke, deserves further investigation.     

Headache in acute stroke. A prospective study in the first 8 days

We aimed to describe and classify headaches associated with acute stroke, by interviewing patients consecutively admitted to a stroke unit using a validated headache questionnaire and the International Classification of Headache Disorders of the International Headache Society (IHS). One hundred and twenty-four patients (61% ischaemic and 39% haemorrhagic stroke) reported headache. Headaches started mostly on the day of stroke, were more often continuous, pressure-type, bilateral and located in the anterior region, were increased by movement and by cough and lasted for a mean of 3.8 days. Tension-type was the most frequent type of headache. Eleven per cent of headaches could not be classified using the criteria of the IHS. Previous primary headache was documented in 71 patients. The presence of nausea/vomiting due to acute stroke can confound headache classification using the IHS criteria. In up to half of the patients, headache seems to be a reactivation of previous primary headache.     

Headache in cerebral hemorrhage is associated with inflammatory markers and higher residual cavity

BACKGROUND AND PURPOSE: The mechanisms responsible for headache in patients with intracerebral hemorrhage (ICH) are not completely understood. The present study was undertaken to analyze the headache-associated factors, the possible related biochemical mechanisms, and the headache potential predictors of outcome in spontaneous ICH. METHODS: We prospectively studied 189 patients from a large cohort of 266 consecutive patients with supratentorial ICH admitted within the first 12 hours of symptoms onset. The presence of headache at stroke onset was evaluated in these patients. The volumes of the initial ICH, peripheral edema at 48 hours, and the residual cavity at 3 months were measured on CT scan. Glutamate, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha levels were measured in blood samples obtained on admission. The Canadian Stroke Scale (CSS) and the modified Rankin Scale were used to evaluate stroke severity and neurological outcome, respectively. RESULTS: Headache at onset of stroke was observed in 65 patients (34.4%). Patients who experienced headache had a significantly higher frequency of history of infection (P= .009) or inflammation (P= .045), as well as higher body temperature (P= .021), leukocyte count (P= .038), ESR (P= .011), and mass effect (P= .017) on admission. Plasma concentrations of IL-6 and TNF-alpha were significantly higher in patients with headache than in those without. Headache was an independent predictor of the residual cavity volume in patients with spontaneous ICH (odds ratio 6.49; 95% CI 2.51 to 16.78; P= .0001). CONCLUSIONS: Headache at ICH onset is associated with clinical and biochemical markers of inflammation and is an independent predictor of higher residual cavity volume after spontaneous ICH.