6.2.1 Headache attributed to non-traumatic intracerebral haemorrhage

Description:

New and usually acute-onset headache caused by non-traumatic intracerebral haemorrhage, associated with focal neurological signs of the intracerebral haemorrhage. It can, rarely, be the presenting and prominent feature of non-traumatic intracerebral haemorrhage.

Diagnostic criteria:
  1. Any new headache fulfilling criteria C and D
  2. Intracerebral haemorrhage (ICH)1 in the absence of head trauma has been diagnosed
  3. Evidence of causation demonstrated by at least two of the following:
    1. headache has developed in close temporal relation to other symptoms and/or clinical signs of ICH, or has led to the diagnosis of ICH
    2. headache has significantly improved in parallel with stabilization or improvement of other symptoms or clinical or radiological signs of ICH
    3. headache has at least one of the following three characteristics:
      • – sudden or thunderclap onset
      • – maximal on the day of its onset
      • – localized in accordance with the site of the haemorrhage
  4. Either of the following:
    1. headache has resolved within 3 months2
    2. headache has not yet resolved but 3 months have not yet passed2
  5. Not better accounted for by another ICHD-3 diagnosis.
Notes:
  1. Through usage, the term intracerebral is taken in this context to include intracerebellar.
  2. The 3 months should be counted from stabilization, spontaneously or through treatment, rather than onset of the intracerebral haemorrhage.
Comments:

6.2.1 Acute headache attributed to non-traumatic intracerebral haemorrhage is more often due to subarachnoid blood and local compression than to intracranial hypertension. It can occasionally present as thunderclap headache.

Headache is more usual and more severe in haemorrhagic than in ischaemic stroke. When occurring at stroke onset, headache is associated with a higher risk of early mortality in intracerebral haemorrhage but not in ischaemic stroke.

The headache is usually overshadowed by focal deficits or coma, but it can be the prominent early feature of some intracerebral haemorrhages, notably cerebellar haemorrhage; this may require emergency surgical decompression.