A Headache: Is it My Usual Migraine or Could it Be a Stroke?
Abstract & Commentary
By Dara G. Jamieson, MD Associate Professor of Clinical Neurology, Department of Neurology and Neuroscience, Weill Medical College, Cornell University. Dr. Jamieson reports she is a retained consultant for Boehringer Ingelheim, Merck, and Ortho-McNeil; and is on the speaker's bureau for Boehringer Ingelheim and Merck.
Synopsis: Patients with a history of migraine headaches are likely to have a headache in association with an acute ischemic stroke. The headaches are migraine-like and often occur with brainstem infarcts.
Source: Nardi K, Parnetti L, Pieri ML, et al. Association between migraine and headache attributed to stroke: a case-control study. Headache 2008 May 9 [Epub ahead of print].
Stroke-associated headache of mild to moderate severity can occur in up to a third of patients with an acute ischemic stroke. Stroke location and etiology correlate with the presence of a headache, as the complaint is common with arterial dissection but rare with stroke due to small vessel occlusion. A posterior circulation infarct is more likely to present with a headache than is an anterior circulation infarct. While patients with a history of migraine headaches are susceptible to multiple headache triggers, their risk of developing a headache with the onset of an acute ischemic stroke is unclear.
Nardi et al investigated the occurrence of headache attributed to acute stroke in a case-control series of 96 acute ischemic stroke patients with a lifetime history of migraine (M+) and in 96 stroke patients without migraine (M-). Patients with hemorrhagic stroke or arterial dissection were excluded. Headache preceded stroke onset by up to 24 hours (a sentinel-onset headache) or occurred at the time of clinical presentation of stroke (an onset headache). The International Classification of Headache Disorders, 2nd Edition (ICHD-II), was used to classify the headache as migraine or tension-type.
Acute stroke patients with a history of migraine complained of headache associated with a stroke more often than did acute stroke patients without migraine (78% vs. 20%, p<0.0001). The headache in migraineurs generally occurred in the 24 hours before the onset of stroke symptoms (p<0.0001); (M+) patients generally had a sentinel-onset rather than an onset headache. Migraine-like, as opposed to tension-type, headaches were recognized in a greater proportion of (M+) patients with ischemic stroke (p<0.018). In the (M-) patient group, the rare headaches were generally tension-type by description. Patients with migraine were more likely to have a brainstem ischemic stroke compared with (M-) patients (p=0.014), who were more likely to have a middle cerebral artery territory infarct. Only 10% of patients with lacunar infarcts on neuroimaging complained of headaches; lacunes were equally likely in the (M-) and (M+) groups.
The authors suggest that the high prevalence of sentinel-onset headaches attributed to stroke in migraine patients may be related to a reduction in pain threshold induced by cerebral ischemia in these headache-prone individuals. The association between migraine-like headache at the onset of posterior circulation ischemia and the predilection for posterior circulation infarcts in patients with migraine is intriguing and poorly understood.
Commentary
Rapid diagnosis of acute ischemic stroke in patients presenting within hours of the onset of neurological symptoms can identify patients who are suitable for thrombolytic or mechanical revascularization. The presence of a prominent headache associated with focal ischemic stroke symptoms may delay appropriate treatment as the diagnosis is being determined. On the other hand, benign causes of headache with focal neurological deficits but negative CT scans of the head, such as migraine with aura or headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL), may be confused with acute ischemic stroke leading to inappropriate treatment. Multiple diagnoses should be considered in a patient with a headache and focal neurological deficits; however, the presence of a headache is not incompatible with an acute ischemic stroke.
Patients with a history of migraine headaches are likely to have a headache in association with an acute ischemic stroke. The headaches are migraine-like and often occur with brainstem infarcts.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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