Headache after hemorrhagic stroke: A systematic review and meta-analysis

Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. While post-stroke care often focuses on motor and functional recovery, post-stroke headaches remain underrecognized and understudied. This study aimed to summarize and pool the evidence on the prevalence and patterns of headaches after hemorrhagic stroke.

We conducted a systematic review and meta-analysis of studies published from database inception to December 2024, identifying observational studies that investigated headaches after hemorrhagic stroke. Studies enrolling five or more adult patients were included. Meta-analyses were conducted to estimate pooled prevalence of overall, acute/subacute, persistent, and severe headaches. Acute/subacute headache was defined as onset within 3 months of stroke, while persistent headache as headache lasting more than 3 months. Severe headache was defined as either a ≥ 7/10 pain intensity or functional impairment.

Twenty-four studies comprising 4688 patients (58.2% female; mean age 56.9) were included. The overall pooled headache prevalence of 46.1% (95% confidence interval [CI]: 36.3%-56.1%; 95% prediction interval [PI]: 4.3%-91.8%; I² = 96.7%) following hemorrhagic stroke. Stratified analyses showed that the prevalence was 58.3% (95% CI: 44.4%-71.6%, I² = 97.5%) in patients with subarachnoid hemorrhage (SAH) and 36.1% (95% CI: 26.7%-46.0%, I² = 93.9%) in those with ICH. Acute/subacute headache occurred in 55.9% (95% CI: 41.1%-70.1%; I² = 97.6%), while persistent headache occurred in 36.7% (95% CI: 25.6%-48.5%, I² = 93.1%). Severe headaches were reported in 42.7% (95% CI: 15.8%-72.1%; I² = 98.0%) of patients with acute/subacute headache and 14.3% (95% CI: 10.4%-18.7%; I² = 71.5%) with persistent headache. In both SAH and ICH, headaches frequently become chronic. No significant differences were observed by study design, geographic region, Human Development Index, or risk of bias.

Headache is a common but understudied condition that can manifest at or soon after a hemorrhagic stroke and can persist for years, potentially contributing to long-term morbidity. Standardized headache definitions and longitudinal assessments are needed to improve recognition and inform future clinical trials targeting this underappreciated source of post-stroke morbidity. Further research is essential to better understand the nature of these headaches, which will help shape treatment protocols and enhance patient care.