6.2.1 Headache attributed to non-traumatic intracerebral haemorrhage

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

Diagnostic criteria:
A. Any new headache fulfilling criterion C
B. Intracerebral haemorrhage (ICH)1 in the absence of head trauma has been diagnosed
C. 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:

      a) sudden or thunderclap onset
      b) maximal on the day of its onset
      c) localized in accordance with the site of the haemorrhage

D. Not better accounted for by another ICHD-3 diagnosis.

Note:
1. Through usage, the term intracerebral is taken in this context to include intracerebellar.

Comments:
6.2.1 Headache attributed to non-traumatic intracerebral haemorrhage is more often due to associated subarachnoid blood and local compression than to intracranial hypertension. Headache is more usual and more severe in haemorrhagic than in ischaemic stroke, and 6.2.1 Headache attributed to non-traumatic intracerebral haemorrhage can occasionally present as thunderclap headache.

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 which may require emergency surgical decompression.