Headache associated with ischemic stroke: a narrative review

Abstract

Introduction
Headache is a common symptom in acute ischemic stroke, with an average prevalence of approximately 14%. Its occurence involves neurovascular dysfunction, meningeal inflammation, and posterior circulation compromise. It is more common in women and in individuals with a history of primary headache. This review aims to describe the clinical, pathophysiological mechanisms, therapeutic considerations and prognostic implications of headache associated with ischemic stroke.
Methods
A narrative review of literature was conducted, using Pubmed/MEDLINE, Scopus, and SciELO databases. Observational studies, secondary literature (systematic reviews and meta-analyses), and international consensus statements published between 2013 and 2025 were included.
Results
Headache occurs in approximately 14% of patients with ischemic stroke, particularly in women, patients with posterior circulation infarcts and those with a history of migraine. Its characterized by moderate to intensity pain, gradual onset, frontal or temporal location, and presents tension-type or migraine-like pattern. Involves meningeal irritation, endothelial dysfunction, alterations in cerebral autoregulation, and activation of the trigeminovascular system. The SNNOOOP10 scale is useful for detecting warning signs and guiding the need for neuroimaging. Paracetamol is the safest analgesic option, NSAIDs, triptans and ergot derivatives should be avoided, CGRP antagonists appear safe, although long-term evidence is limited.
Conclusion
Headache associated with ischemic stroke is a relevant clinical manifestation with diagnostic and prognostic implications. Its recognition and appropriate management require a careful balance between analgesic efficacy and vascular safety.