Acute headache attributed to ischaemic stroke (cerebral infarction)


New and usually acute-onset headache caused by ischaemic stroke and associated with focal neurological signs of the stroke. It is very rarely the presenting or a prominent feature of ischaemic stroke. It usually has a self-limiting course.

Diagnostic criteria:
  1. Any new headache fulfilling criteria C and D
  2. Acute ischaemic stroke has been diagnosed
  3. Evidence of causation demonstrated by either or both of the following:
    1. headache has developed in very close temporal relation to other symptoms and/or clinical signs of ischaemic stroke, or has led to the diagnosis of ischaemic stroke
    2. headache has significantly improved in parallel with stabilization or improvement of other symptoms or clinical or radiological signs of ischaemic stroke
  4. Either of the following:
    1. headache has resolved within 3 months1
    2. headache has not yet resolved but 3 months have not yet passed1
  5. Not better accounted for by another ICHD-3 diagnosis.

The 3 months should be counted from stabilization, spontaneously or through treatment, rather than onset of the ischaemic stroke.

Comments: Acute headache attributed to ischaemic stroke (cerebral infarction) is accompanied by focal neurological signs and/or alterations in consciousness, which in most cases allows easy differentiation from the primary headaches. It is usually of moderate intensity, and has no specific characteristics. It can be ipsilateral to the stroke or bilateral. Rarely, an acute ischaemic stroke, notably an embolic cerebellar or supratentorial infarction, can present with an isolated sudden (even thunderclap) headache.

Headache accompanies ischaemic stroke in up to one third of cases; it is more frequent in basilar- than in carotid-territory strokes. It is of little practical value in establishing stroke aetiology except that headache is very rarely associated with lacunar infarcts.

Headache is, however, extremely common in acute arterial wall disorders that may lead to ischaemic stroke, such as arterial dissection or reversible cerebral vasoconstriction syndrome. In these latter conditions, headache may be directly caused by the arterial wall lesions, and may precede ischaemic stroke; it is then more correctly coded to the arterial wall disorder.