Blood pressure control after intracerebral haemorrhage cuts recurrence by a third

The edition in brief

The lead finding is the clearest statement yet of what secondary prevention after intracerebral haemorrhage is worth. RECAP-ICH pooled individual participant data from four randomised trials, 2,944 survivors of spontaneous intracerebral haemorrhage, three quarters of them Asian, followed for a median 42 months. A mean systolic difference of 11.2 mmHg reduced first recurrent stroke of any type from 10.4% to 6.5% (adjusted hazard ratio 0.62, 95% CI 0.48 to 0.80), driven almost entirely by recurrent haemorrhage falling from 5.6% to 2.2% (adjusted HR 0.39, 95% CI 0.26 to 0.59). Serious adverse events were no higher. Time to a 1% absolute benefit was 6.1 months, and effects held across age, sex, region, baseline blood pressure and time since the index event. TEMPLE compared atogepant 60 mg with topiramate head to head in 540 adults over 24 weeks. Discontinuation for adverse events was 12% versus 30% (relative risk 0.4), and at least 50% reduction in monthly migraine days was 64% versus 39% (relative risk 1.6). The AAN and American Headache Society have published an updated migraine prevention guideline alongside it. The EURAP registry, 15,893 exposed pregnancies, found antiseizure polytherapy lowered birthweight centile and raised small-for-gestational-age risk by about 50%. Among monotherapies, topiramate was worst, nearly 12 centiles below lamotrigine. STRATEGY randomised 970 patients with branch atheromatous disease stroke to tirofiban plus aspirin or aspirin alone and found no benefit (hazard ratio 0.88, 95% CI 0.65 to 1.19).