ISC 2026 | Best practices for managing post-hemorrhagic stroke headache
Bradley Ashley Ong, MD, Cleveland Clinic, Cleveland, OH, comments on the management of post-hemorrhagic stroke headache. Dr Ong emphasizes the importance of ruling out secondary headaches, using a multimodal treatment plan, as well as addressing other contributors such as mental health issues, sleep, and stress regulation. This interview took place at the 2026 International Stroke Congress (ISC), held in New Orleans, LA.
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Transcript
So we really don’t have a strong evidence-based specific approach in managing our post-hemorrhagic stroke headache patients. There are no clinical trials out there. If there are studies, it’s usually retrospective in nature. And that’s kind of like one of the limiting factors that we also discovered. So a lot of the time when we’re seeing patients in our clinic, it’s more so extrapolated from primary headache guidelines, from primary headache studies out there...
So we really don’t have a strong evidence-based specific approach in managing our post-hemorrhagic stroke headache patients. There are no clinical trials out there. If there are studies, it’s usually retrospective in nature. And that’s kind of like one of the limiting factors that we also discovered. So a lot of the time when we’re seeing patients in our clinic, it’s more so extrapolated from primary headache guidelines, from primary headache studies out there. And we also determine it based on the headache phenotype, whether it’s migraine-like or tension-like in type of headache. But in terms of best practices, I like to think of it in a three-prong approach, wherein the first one, if a patient comes in, we have to make sure that we’re not missing a secondary type of headache, that it’s not dangerous. There are no red flags in their headache. Or could it be a complication of their stroke, such as vasospasm, or pressure changes in their brain? And that should ring alarm bells to further work these patients up. The second would be timing as well as treatment of these patients. The timing and the treatment, what I’m saying here is we should do a multimodal approach or a plan for our patients. And we have to be very careful when we’re recommending medications, especially in our setting. We try to shy away from giving these patients opioid medication, not only because it doesn’t seem to help, but rather sometimes these patients would have rebound type of headache worse than what they initially had. The third approach that I do is also look into the contributors that can perpetuate chronic pain. A lot of these patients, a lot of our stroke patients would have either problems with mental health, anxiety, depression, just because of their poor quality of life, a lot of these other stroke symptoms can also linger. So targeting these things can help with our patients, those who are having persistent headache, even sleep or even sometimes mood symptoms and stress regulation can help with our patients with persistent post-stroke headache.
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BO serves as a member of the Neurology® Resident & Fellow Section Editorial Board and has participated as an uncompensated host for the Neurology Minute podcast of the American Academy of Neurology.
