New studies have shown that women with stroke have symptoms other than the classic ones, such as paralysis and speech difficulties. Paramedics may misinterpret these symptoms as migraine, confusion, or high blood pressure.

Stroke symptoms in young women are different than in men

Women may have different stroke symptoms than men. They often do not have the classic symptoms such as slurred speech, difficulty smiling or lifting an arm. A lack of awareness can delay life-saving treatment.

Blood clots in the brain can cause serious damage without rapid medical help. Every minute counts, and you must call an ambulance if you suspect a stroke.

In 2015, the Norwegian Directorate of Health launched the campaign "Talk, smile, lift" to make the population aware of stroke symptoms.

Difficulty talking, smiling, or moving an arm can be caused by paralysis after a stroke.

But new research shows that these classic symptoms don’t apply to everyone, according to an article in (link in Norwegian), published by the Norwegian Medical Association.

7 of 10 have classic symptoms

More than 70 per cent of all strokes were characterized by one or more symptoms such as speech difficulties, paralysis of the face or arm, an evaluation of the Health Directorate’s campaign showed.

The remainder, as many as three out of ten patients, did not have these symptoms.

“These patients were probably diagnosed later and perhaps did not get to the hospital in time to receive the treatment they needed,” said Maren Ranhoff Hov to

Ranhoff Hov is a senior researcher at the Department of Neurology, Oslo University Hospital (OUS) and one of the authors of the article published in

Getting to the hospital quickly is essential

It is absolutely crucial to get to hospital in time if you have a stroke, Ranhoff Hov said.

Ambulance personnel are trained to focus on facial paralysis and the like.

“But if the ambulance service does not recognize symptoms of a stroke, it can lead to delayed treatment,” Ranhoff Hov, who also teaches paramedicine at Oslo Metropolitan University (OsloMet), said.

Treating cerebral infarction

Strokes are caused by either blood clots in the brain (85 per cent), or brain haemorrhage.

A CT or MR image of the head must be taken before treatment, to differentiate between cerebral haemorrhage and cerebral infarction (blood clot).

Cerebral infarction can be treated with clot-dissolving drugs, mechanical removal of the clot or a combination.

This reduces the risk of problems like paralysis after a stroke.

Thrombolysis: Medicines that dissolve the blood clot are also called "plumbing treatment". Treatment should start as early as possible, preferably within 3 hours, but can be given up to 4.5 hours from the onset of symptoms.

Thrombectomy: Mechanical "removal" of the blood clot. Mostly used if the clot is too large to be dissolved by thrombolysis. A thin catheter is inserted into an artery in the groin and further up to the brain to the place where the clot is located.

Sources: LHL, the Directorate of Health and the Medicines Handbook

Younger women have different symptoms

Hov and her co-authors discuss a number of new studies about stroke.

For example, women under the age of 70 who suffer a stroke have other, more diffuse symptoms, according to a new population-based study from Australia with more than 200,000 participants.

Women more often have a general feeling of illness, weakness, anxiety, nausea and headaches. And their consciousness can be affected.

Paramedics more often misinterpret their symptoms as a migraine, confusion or high blood pressure, according to two recently published meta-analyses.

“This is a large group that isn’t detected. This is completely new information that demonstrates the need for more research on women and stroke,” says Ranhoff Hov.

Neurologists Else Charlotte Sandset and Maren Ranhoff Hov want to focus more on women's stroke symptoms, which are different from the classic ‘talk, smile, lift’ signs.

Valuable minutes wasted

Because a woman’s symptoms are so different from what is considered the norm, paramedics often first assess whether other injuries or illnesses are the cause of the problem.

Misinterpretation of stroke symptoms can lead to younger women receiving delayed emergency treatment.

As a result, they may have a worse prognosis, such as paralysis and other functional impairments that are difficult to treat.

In the case of cerebral infarction, a delay of even a few minutes before the patient receives treatment is decisive in the prognosis.

“After four-and-a-half hours, it is too late to offer thrombolysis as a treatment, for example,” Ranhoff Hov, who is also a fellow at the Norwegian Air Ambulance Foundation, said.

Letting the hospital know

It is important for paramedics to quickly identify stroke symptoms. They can then notify the hospital in advance so that the patient is admitted quickly, the authors wrote.

Then emergency treatment can start without delay.

A stroke that is caused by a blood clot is treated by removing the blood clot either with clot-dissolving drugs or by mechanical extraction.

Is the brain affected differently?

Stroke symptoms originate from the area of the brain that has been affected by reduced blood supply.

How the brain is affected by a stroke can be different in women and men, studies suggest.

This may be the reason for the difference in symptoms between women and men.

It has long been known that women are more severely affected after a stroke than men. More women become disabled due to disabilities after stroke than men.

A new tool needed

Stroke patients with atypical stroke symptoms are at risk because of the lack of mandatory training about the issue in the ambulance service, says Ranhoff Hov.

Both the general population and health personnel need to have a greater awareness of the gender-related differences in stroke symptoms, the researchers say.

“The guidelines for treatment must be updated to include these diffuse symptoms,” she says.

The emergency services evaluation tools should also include cognitive skills, coordination and orientation, the article's authors wrote.

New studies on stroke should also include gender differences in their analyses.

The FAST survey

Pre-hospital personnel and the general population have been trained to recognize symptoms associated with 70 per cent of stroke patients.

The ambulance service uses what is called the FAST examination, which stands for Face, Arm, Speech, Time.

The abbreviation refers to the same three symptoms as in the Norwegian Directorate of Health's campaign, and also emphasizes that time is critical in providing treatment.

Heart attack symptoms can be different

Heart attack symptoms are also often different in women than in men.

While men have characteristic chest pain with radiation to the arm and neck, women have more diffuse symptoms.

This has led to greater focus on the female heart and women's symptoms of heart disease.

Translated by Nancy Bazilchuk


Xia Wang Differences in the pre-hospital management of women and men with stroke by emergency medical services in New South Wales. The Medical Journal of Australia, 13 July 2022.

Sultana Shajahan, Else Charlotte Sandset : Sex differences in the symptom presentation of stroke: A systematic review and meta-analysis. International Journal of Stroke, 12 April 2022. (Summary)

Mariam Ali Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis. Stroke, 14 December 2021.


Read the Norwegian version of this article at

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