Persistent Poststroke Headache: Finding Its Place in Stroke Aftercare

older woman holding her head
older woman holding her head
The continued observation of this delayed headache syndrome may point to a different pathophysiology from tension-type headache or acute poststroke headache.

Headache occurring as a consequence of stroke is a common complaint, identified as far back as 1984 by Portenoy et al1 in a limited study of 163 patients after cerebrovascular events. The Portenoy study found that 60% of headaches started before the stroke and 25% began at the same time as the stroke.1 The Copenhagen study in 1994 followed up with reports that in a cohort of 1128 consecutive patients with acute stroke, the prevalence of headache was 28% and occurred more often in patients who had experienced a vertebrobasilar stroke compared with those who experienced stroke in the carotid region.2 Stroke severity did not seem to be a factor.

Since that time, multiple studies have reported on stroke-related headache, with an incidence ranging from 9.3% to 38%.3 More recently, however, exploration of different patterns of headache has revealed a long-term, persistent headache as a sufficiently distinct entity, enough to warrant entry as a new category in the International Classification of Headache Disorders (ICHD)-3.4,5

The clinical utility of this new designation is not yet clear. “Acute stroke-related headache is not uncommon, reported in 23% to 54% of stroke patients,” Peter McAllister, MD, medical director of the New England Institute for Neurology and Headache and chief medical officer for the New England Institute for Clinical Research in Stamford, Connecticut, told Neurology Advisor. “It is often self-limited and resolves in days, weeks or a few months. Persistent poststroke headache is less well understood, other than we know, by definition, that it persists.”

In an editorial, Singapore rehabilitation clinician Tze Chao Wee, MBBS, pointed to a number of challenges to the distinction of persistent poststroke headache (PPSH), including association of the 2 events in the first place, as many patients are drowsy in the hours or days after a stroke.6 The second problem is with the characterization of PPSH, and defining whether it even “crosses the threshold” for a primary headache.

Distinguishing Acute From PPSH

The main difference appears to be timing of the headache. The ICHD-3 defines acute poststroke headache as headache that occurs with 72 hours after stroke, although some studies allow for up to 7 days.4 In their review, Lai et al5 found a prevalence of PPSH of 23% after ischemic or hemorrhagic stroke, whereas a 3-year follow-up study conducted by Hansen and colleagues3 in Denmark reported that 12% of 222 patients with stroke who were sent a questionnaire developed a new headache.

The defining feature of persistence, according to the ICHD-3 classification, is continuation of pain lasting for 3 months to years, in association with a documented previous ischemic stroke, nontraumatic intracranial hemorrhage, cervical artery dissection, or reversible cerebral vasoconstriction syndrome.

Diagnosing PPSH

One of the challenges to PPSH is that it presents after the patient has been discharged from the hospital for stroke care, and given the time delay, it may not be initially recognized as a related symptom to stroke. “PPSH, if diagnosed at all, will be in an outpatient setting,” Dr McAllister said. “Given the etiologic cause, clinicians may interpret a lingering headache, particularly after a hemorrhagic stroke, as a red flag requiring imaging. Once we get a better handle on accurate diagnosis of PPSH, we’ll be able to save patients from unnecessary imaging procedures.”

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Once diagnosed, treatment for PPSH is currently symptomatic. “It presents mostly as a tension-type headache, so we treat that phenotype: simple analgesics, being careful not to overdo [nonsteroidal anti-inflammatory drugs], as they increase stroke risk. If the headaches are frequent, a daily preventive medicine such as low-dose amitriptyline may be considered,” Dr McAllister observed.

What Does a New Poststroke Headache Type Suggest?

The continued observation of this delayed headache syndrome may point to a different pathophysiology from tension-type headache or acute poststroke headache, and the presence of PPSH may suggest additional risks for psychological complications, such as anxiety, fatigue, and particularly depression.5

According to Huma Shiekh, MD, a headache specialist at Mount Sinai Hospital in New York City, the additional ICHD-3 designation of PPSH can also be helpful for research purposes, to further explore these issues. “In order to do research on a specific headache subtype, it is important to have a cohort of patients that you feel fit into that subtype. With headaches, this is usually first done by characterization of the headache,” she told Neurology Advisor.

“While folks with acute poststroke headache may develop PPSH, most don’t. Thus, PPSH likely represents a different entity, with a different pathophysiology. We need to better understand risk factors for PPSH. Depression may be a risk factor,” Dr McAllister said, noting that, “Again, more work needs to be done.”

Lai and colleagues pointed out in their review that, as PPSH has only recently been designated a separate entity from acute poststroke headache, further exploration of its epidemiology and natural history may have important implications for stroke rehabilitation outcomes and quality of life for stroke survivors.5


  1. Portenoy RK, Abissi CJ, Lipton RB, et al. Headache in cerebrovascular disease. Stroke. 1984;15:1009-1012.
  2. Jørgensen HS, Jespersen HF, Nakayama H, Raaschou HO, Olsen TS. Headache in stroke: the Copenhagen Stroke Study. Neurology. 1994;44:1793-1797.
  3. Hansen AP, Marcussen NS, Klit H, et al. Development of persistent headache following stroke: a 3-year follow-up. Cephalalgia. 2015;35:399-409.
  4. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629-808.
  5. Lai J, Harrison RA, Plecash A, Field TS. A narrative review of persistent post-stroke headache – a new entry in the International Classification of Headache Disorders, 3rd edition [published online August 27, 2018]. Headache. doi: 10.1111/head.13382
  6. Wee TC. Poststroke headache: An underdiagnosed entity?Am J Phys Med Rehabil. 2018;97:e56-e57.