Medications and Stroke Risk: What drugs cause strokes?

October 7, 2025 •

6 min read

According to a 2021 review, a limited number of drugs have a high level of association with ischemic stroke. This article explores what drugs cause strokes, both illicit and prescribed, and the mechanisms behind these risks.

Quick Summary

Certain medications and illicit drugs, including stimulants, hormonal contraceptives, NSAIDs, and herbal supplements, can increase stroke risk by affecting blood vessels and clotting.

Key Points

Illicit Drug Risks: Stimulants like cocaine and methamphetamine are strongly linked to both ischemic and hemorrhagic strokes, primarily by causing vasospasms and dangerous blood pressure spikes.
Hormonal Therapies and Clotting: Combined hormonal contraceptives and oral hormone replacement therapy increase blood clotting risk, especially for women with conditions like migraines with aura or high blood pressure.
NSAID Caution: Non-aspirin NSAIDs (ibuprofen, naproxen) can raise blood pressure and increase the risk of heart attack and stroke, with the risk higher at increased doses or with long-term use.
Herbal Supplement Dangers: Some herbal products, such as ginkgo biloba (bleeding risk) and the banned ephedra (heart and stroke risk), can pose significant dangers, especially when combined with other medications.
Open Communication is Key: Always inform your healthcare provider about all substances you use, including prescription medications, over-the-counter drugs, and supplements, to properly assess and manage your individual risk.
Risks Evolve with Time and Dose: Stroke risk associated with certain drugs, like hormonal therapies, can be highest during the initial phase of treatment or with higher doses, and may depend on factors like age and duration of use.
Alternative Medication Considerations: For individuals with multiple stroke risk factors, progesterone-only birth control methods or non-hormonal options may be safer than combined hormonal contraceptives.

A stroke occurs when the blood supply to part of the brain is interrupted, either by a blockage (ischemic stroke) or bleeding (hemorrhagic stroke). While lifestyle factors and genetics play significant roles, certain medications and illicit substances can also increase your risk. Understanding how these drugs affect the body is crucial for mitigating potential harm.

Illicit and Recreational Drugs

Stimulants: Cocaine and Amphetamines

Stimulant use is strongly associated with an increased risk of stroke, particularly in younger adults. Cocaine and amphetamines, including methamphetamine, cause a sudden and dramatic increase in blood pressure and heart rate. This "sympathetic surge" can lead to several dangerous effects:

Cerebral Vasospasm: A severe narrowing of the brain's blood vessels, which can cause a lack of oxygen and lead to an ischemic stroke.
Hypertensive Surges: A rapid spike in blood pressure can cause a hemorrhagic stroke, where a blood vessel in the brain ruptures and bleeds.
Enhanced Platelet Aggregation: Stimulants can make blood platelets stickier, increasing the risk of forming blood clots that can travel to the brain.
Vasculitis: Some stimulant users may develop inflammation of the blood vessels, leading to damage and potential rupture.

Cannabis and Synthetic Cannabinoids

While the link is not as strong as with other stimulants, growing evidence suggests cannabis use may increase stroke risk, especially with synthetic versions like "Spice" or K2. Synthetic cannabinoids can cause a high incidence of adverse effects, including increased heart rate, blood pressure, and cardiac ischemia. The mechanism for cannabis-related strokes is not fully understood, but it may involve vasospasm, changes in blood clotting, or oxidative stress.

Opioids

Heroin and other opioids are primarily linked to stroke through indirect complications, particularly infective endocarditis in intravenous drug users. The use of non-sterile needles can introduce bacteria into the bloodstream, leading to heart valve infections. Fragments of these infected valves can break off and travel to the brain, causing a septic cardioembolic stroke.

Prescription Medications with Increased Stroke Risk

Hormonal Contraceptives and Hormone Replacement Therapy

Hormonal therapies, particularly those containing estrogen, are a well-documented risk factor for stroke.

Combined Hormonal Contraceptives (oral pills, vaginal rings, patches): Estrogen increases blood-clotting factors, creating a hypercoagulable state. The risk is generally low for healthy individuals but significantly increases with other risk factors like smoking, high blood pressure, and migraines with aura. Progestin-only methods carry a lower risk. The risk is highest during the first year of use.
Oral Hormone Replacement Therapy (HRT): Used to manage menopausal symptoms, oral estrogen HRT has also been shown to increase stroke risk, particularly ischemic stroke and subarachnoid hemorrhage. The risk is highest in the first year and with increasing age, especially when initiated 10 or more years after menopause begins. Transdermal patches may carry a lower risk than oral forms.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

For several years, the FDA has strengthened warnings that non-aspirin NSAIDs, both prescription and over-the-counter, can increase the risk of heart attack and stroke. The risk is present even with short-term use and increases with higher doses and longer duration. NSAIDs can elevate blood pressure and interfere with the heart-protective antiplatelet action of aspirin.

Other Prescription Drugs

Antihypertensives: Paradoxically, some antihypertensive medications, such as Angiotensin Receptor Blockers (ARBs) and Beta-blockers, have been linked to an increased risk of incident stroke in older adults. This may be due to factors like blood pressure variability rather than a direct drug effect. It's important to note that the benefits of controlling blood pressure generally outweigh this potential risk, but it underscores the complexity of managing cardiovascular health.
Antipsychotics: Some studies have shown an increased risk of stroke associated with certain antipsychotic medications.
Immunomodulators and Chemotherapy: Specific cancer treatments like bevacizumab and tamoxifen have documented links to increased stroke risk. Alemtuzumab, used for multiple sclerosis, carries a black box warning for stroke.

Over-the-Counter (OTC) Medications and Supplements

Beyond NSAIDs, certain OTC products and herbal supplements can carry risks. For instance, nasal decongestants containing pseudoephedrine or the now-banned phenylpropanolamine (PPA) have been linked to stroke due to their sympathomimetic (blood pressure-raising) effects. Herbal supplements can also pose a risk:

Ephedra (Ma-Huang): Banned by the FDA due to its link with heart attacks, strokes, and death.
Ginkgo Biloba: Known for its blood-thinning properties, it can increase the risk of bleeding, which is dangerous for those at risk of hemorrhagic stroke or already on anticoagulant medications.
Other blood thinners: Herbs like turmeric, ginger, and fish oil can also have antiplatelet effects and should be used with caution.

How Medications Trigger Strokes

The mechanisms by which drugs can increase stroke risk are varied and complex. These include:

Prothrombotic Effects: Many drugs, especially those containing estrogen, increase the production of blood-clotting factors while decreasing natural anticoagulant proteins, leading to a higher risk of clots forming and causing an ischemic stroke.
Hypertension and Vasospasm: Stimulant drugs cause an abrupt increase in blood pressure and constriction of blood vessels (vasospasm), which can lead to hemorrhagic or ischemic strokes.
Vasculitis: Inflammation of the blood vessels can weaken their walls, increasing the risk of rupture (hemorrhagic stroke).
Cardioembolism: Damage to the heart, such as infective endocarditis from IV drug use, can cause infected material to break off and travel to the brain, leading to a stroke. Some supplements like fish oil have been linked to atrial fibrillation, a cardiac arrhythmia that can cause clots to form in the heart.

Managing Your Risk: A Proactive Approach

Taking an active role in managing your health and medication use can significantly reduce your stroke risk. Key steps include:

Communicate openly with your doctor: Disclose all medications, including OTC drugs, vitamins, and herbal supplements, and discuss any illicit drug use.
Measure your blood pressure: Regular checks are critical, especially if you take medication or have other risk factors. The American Heart Association provides extensive resources on blood pressure management.
Manage underlying conditions: Take steps to control high blood pressure, diabetes, high cholesterol, and atrial fibrillation, as these can amplify drug-related risks.
Avoid recreational drugs: The high and unpredictable risks associated with illicit drugs like cocaine and amphetamines make abstinence the safest option.
Be aware of combination risks: The danger can be compounded when combining substances. For instance, using NSAIDs with opioids has been linked to higher cardiovascular risk in older adults.

Drug-Related Stroke Risk: A Comparative Look


Drug Category	Examples	Primary Mechanism(s)	Stroke Type Risk	Key Associated Factors
Illicit Stimulants	Cocaine, Methamphetamine	Vasospasm, Hypertensive Surges, Platelet Aggregation	Both Ischemic and Hemorrhagic	Often younger users, higher doses, rapid onset
Combined Hormonal Contraceptives	Estrogen-progestin pills, patches	Increased Blood Clotting Factors	Ischemic	Smoking, high blood pressure, migraine with aura
Oral Hormone Replacement Therapy	Oral estrogen + progestogen	Increased Blood Clotting Factors	Ischemic, Subarachnoid Hemorrhage	Use timing (especially first year), age, dose
Non-Aspirin NSAIDs	Ibuprofen, Naproxen	Increased Blood Pressure, Interference with Aspirin	Ischemic, Cardiac Events	High doses, long-term use, pre-existing heart disease
Certain Antihypertensives	ARBs, Beta-blockers (in some cases)	Blood pressure variability	Ischemic	Older adults; overall benefit vs risk is key consideration
Herbal Supplements	Ephedra, Ginkgo Biloba	Vasoconstriction, Increased Bleeding	Varies (Ischemic/Hemorrhagic)	Dependent on herb; interactions with other meds are key

Conclusion

While many medications are critical for managing health conditions, some carry a documented risk of stroke by affecting blood vessels, blood clotting, and blood pressure. Illicit drugs, especially stimulants, have a strong association with severe cerebrovascular events, often affecting younger individuals. Similarly, combined hormonal therapies and non-aspirin NSAIDs are linked to an increased risk, particularly in individuals with pre-existing risk factors. Proactive management involves open communication with healthcare providers, disclosing all substance use, and weighing the benefits and risks of any medication. For individuals concerned about their stroke risk, exploring safer alternatives and prioritizing lifestyle adjustments are crucial steps toward prevention. The link between certain drugs and stroke is an important area of ongoing research, highlighting the need for vigilance and informed decisions when managing health.

American Heart Association Journals: Drugs Associated With Ischemic Stroke - A Review for Clinicians

Frequently Asked Questions

Yes, non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen can increase the risk of heart attack and stroke, especially with higher doses and longer durations of use. These drugs can elevate blood pressure and interfere with aspirin's antiplatelet effects.

No. The increased stroke risk is primarily associated with combined oral contraceptives that contain estrogen. Progestin-only pills, patches, and implants carry a lower risk. For women with pre-existing risk factors like migraines with aura, smoking, or high blood pressure, non-estrogen options are often recommended.

Cocaine use is associated with a high risk of stroke due to its effects on the cardiovascular system. It causes blood vessels to constrict (vasospasm), increases blood pressure dramatically, and enhances platelet aggregation, all of which can lead to a stroke.

Studies show that the increased risk of stroke from oral HRT, particularly for ischemic stroke, is highest during the first year of use. The risk may gradually decline with longer use, but it remains a consideration throughout treatment.

No. Many herbal supplements can interfere with prescribed medications or have unintended side effects. For example, ginkgo biloba has blood-thinning properties that can increase the risk of bleeding for individuals with hemorrhagic stroke history or those on anticoagulants. Always consult a doctor before taking any supplements.

Stimulant use is associated with both hemorrhagic and ischemic strokes. Hemorrhagic strokes, or bleeding in the brain, are often caused by sudden and severe increases in blood pressure triggered by stimulants. Ischemic strokes can result from vasospasms or enhanced blood clotting.

Yes. According to guidelines from the American College of Obstetricians and Gynecologists, women with migraines with aura have an increased risk of ischemic stroke and should consider using progestin-only or non-hormonal contraceptive methods.

While the overall goal of antihypertensive medication is to reduce stroke risk, some studies have found associations between certain classes (e.g., ARBs and Beta-blockers) and a higher risk of incident stroke in older adults. This may be due to complex factors like blood pressure variability, but the benefits of controlled blood pressure generally outweigh this finding.

The link is not as definitive as with stronger stimulants like cocaine, but evidence suggests a possible association, particularly with synthetic cannabinoids. The American Stroke Association has called the potential link "interesting but not yet definitive".