What drugs can cause hemorrhagic stroke?

October 12, 2025 •

4 min read

In young adults between 15 and 44, drug users are 6.5 times more likely to experience a stroke than non-users [1.5.6]. Understanding what drugs can cause hemorrhagic stroke is critical for both patient awareness and clinical risk assessment.

Quick Summary

Certain prescription medications, such as anticoagulants and antiplatelets, and illicit drugs like cocaine and amphetamines, are known to increase the risk of hemorrhagic stroke by impairing coagulation or causing sudden spikes in blood pressure [1.2.1, 1.4.5].

Key Points

Anticoagulants and Antiplatelets: Prescription blood thinners like warfarin and antiplatelet drugs like aspirin increase the risk by impairing the body's natural clotting ability [1.3.1, 1.4.2].
Illicit Stimulants: Cocaine and amphetamines are strongly linked to hemorrhagic stroke, primarily by causing a sudden, severe spike in blood pressure that can rupture vessels [1.5.1].
Hypertension is a Multiplier: The presence of uncontrolled high blood pressure dramatically increases the stroke risk associated with these medications and substances [1.2.2, 1.6.3].
Combination Therapy Risk: Combining different types of blood thinners, such as an anticoagulant and an antiplatelet agent, significantly elevates the risk of a major hemorrhage [1.4.2].
Dose and Monitoring Matter: For medications like warfarin, the risk of ICH is markedly higher with an elevated INR, highlighting the importance of regular medical monitoring [1.3.5].
Age Increases Risk: The incidence of anticoagulant-associated brain hemorrhages increases significantly with age, especially in those over 80 [1.2.8].
Even OTC Drugs Pose a Risk: Certain over-the-counter drugs, like the decongestant phenylpropanolamine (now removed from most markets), were linked to an increased risk of hemorrhagic stroke [1.3.7].

Understanding Hemorrhagic Stroke

A hemorrhagic stroke occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue (intracerebral hemorrhage) or the space around the brain (subarachnoid hemorrhage) [1.6.9]. This is different from an ischemic stroke, which happens when a clot blocks blood flow to the brain [1.2.1]. While hemorrhagic strokes make up only about 13% of all strokes, they are responsible for a higher percentage of stroke-related deaths [1.6.9, 1.3.6]. The accumulated blood from the rupture compresses brain tissue, leading to neurological damage [1.6.9]. A drug-induced stroke can occur through several mechanisms, including causing severe hypertension, impairing blood coagulation, or inducing vasculopathy (diseased blood vessels) [1.2.1].

Prescription Drugs That Increase Bleeding Risk

Many life-saving medications carry an inherent risk of bleeding, which can lead to a hemorrhagic stroke, especially if not managed properly.

Anticoagulants (Blood Thinners)

These medications are prescribed to prevent harmful blood clots in patients with conditions like atrial fibrillation [1.4.5]. By design, they interfere with the body's clotting cascade. While effective, this action increases the risk of bleeding. Approximately 20% of patients who suffer a brain hemorrhage are taking an anticoagulant [1.3.1].

Examples: Warfarin, Rivaroxaban (Xarelto), Dabigatran (Pradaxa), Apixaban (Eliquis) [1.3.1].
Mechanism: These drugs inhibit clotting factors. Warfarin use, in particular, is associated with a greatly increased risk of intracerebral hemorrhage (ICH), and the risk is markedly higher if the international normalized ratio (INR), a measure of blood clotting time, is above 3.0 [1.3.5, 1.3.2].

Antiplatelet Agents

Antiplatelet drugs prevent platelets from clumping together to form a clot. They are commonly used for cardiovascular disease prevention. Combining antiplatelet drugs or using them with anticoagulants can significantly increase the risk of hemorrhage [1.4.2, 1.4.6].

Examples: Aspirin, Clopidogrel (Plavix) [1.4.2].
Mechanism: Studies show that while low-dose aspirin alone may not be associated with a significantly increased risk of ICH for some, the risk elevates when combined with other antithrombotic drugs [1.3.5, 1.3.4]. For instance, the combination of rivaroxaban and aspirin shows a high hemorrhage risk [1.4.2].

Other Prescription Medications

Thrombolytics ("Clot Busters"): Drugs like Alteplase (tPA) are used to dissolve clots during an acute ischemic stroke. However, a major known complication of this treatment is causing a secondary hemorrhagic stroke [1.3.1].
Antidepressants: The combined use of antidepressants with NSAIDs has been associated with a 60% increased risk of intracranial hemorrhage within 30 days of use [1.3.3]. The mechanism is thought to relate to effects on platelet function [1.2.1].
Statins: Some studies suggest that statins, used for lowering cholesterol, may modestly increase the risk of hemorrhagic stroke, particularly at high doses [1.2.9, 1.3.9].

Illicit Drugs and Stimulants

Illicit drug use is a major cause of stroke, especially in younger individuals [1.5.3]. The primary mechanism for many of these substances is a sudden and severe increase in blood pressure (hypertensive surge), which can rupture brain arteries [1.2.2, 1.6.3].

Sympathomimetic Drugs

This class includes powerful stimulants that have a strong link to both ischemic and hemorrhagic strokes [1.2.4].

Cocaine: Cocaine abuse is strongly associated with both hemorrhagic and ischemic strokes [1.5.1]. It can cause a sharp increase in blood pressure and vasospasm (constriction of blood vessels) [1.2.6, 1.2.4]. Hemorrhagic strokes are disproportionately high in cocaine-related stroke events [1.5.8].
Amphetamines: Amphetamine use is associated with a nearly five-fold increased risk of hemorrhagic stroke [1.5.1]. Like cocaine, they cause a hypertensive surge. Some evidence also points toward amphetamine use causing vasculitis (inflammation of blood vessels), which weakens vessel walls [1.2.2]. Examples include methamphetamine and prescription stimulants like Adderall when abused [1.2.3].
Phenylpropanolamine (PPA): This former ingredient in cold remedies and appetite suppressants was withdrawn from the market due to evidence of an increased risk of hemorrhagic stroke [1.3.7, 1.6.3].

Comparison of Drug Classes and Hemorrhagic Stroke Risk


Drug Class	Examples	Primary Mechanism of Risk	Relative Risk Level
Anticoagulants	Warfarin, Apixaban	Impaired blood clotting cascade [1.3.1]	High [1.3.5]
Antiplatelets	Aspirin, Clopidogrel	Inhibition of platelet aggregation [1.4.2]	Low to Moderate (Increases with combination therapy) [1.3.5, 1.4.6]
Sympathomimetics	Cocaine, Amphetamines	Acute hypertensive surge, vasospasm, vasculitis [1.2.2, 1.2.4]	Very High [1.5.1]
NSAIDs	Ibuprofen, Naproxen	Mild platelet inhibition, potential blood pressure effects [1.3.3]	Low [1.3.3]

Factors That Amplify Risk

The risk of a drug-induced hemorrhagic stroke is not uniform and is significantly increased by underlying conditions:

Uncontrolled Hypertension: This is the most critical risk factor that compounds the danger from other drugs [1.2.2, 1.6.3].
Pre-existing Vascular Abnormalities: Individuals with brain aneurysms or arteriovenous malformations (AVMs) are at very high risk, as a drug-induced pressure spike can cause a rupture [1.2.2, 1.6.7].
Advanced Age: The risk of bleeding complications from anticoagulants increases with age [1.2.8].
Combination Drug Use: Combining anticoagulants with antiplatelets significantly raises the risk of a major bleed [1.4.2].

Conclusion

While many medications are essential for treating and preventing disease, it is crucial to recognize their potential risks. Anticoagulants, antiplatelets, and both illicit and prescription stimulants are all linked to an increased risk of hemorrhagic stroke [1.2.1]. The danger from prescription drugs is primarily related to their intended effects on the blood's clotting ability, while the risk from stimulants stems from their capacity to induce dangerously high blood pressure [1.2.4, 1.3.1]. Patient education, careful medical supervision, regular blood pressure monitoring, and avoiding illicit substance use are cornerstone strategies for mitigating the risk of this devastating event. Always discuss the risks and benefits of your medications with your healthcare provider.

For further reading, you can consult the American Heart Association's resources on stroke: https://www.stroke.org/en/about-stroke/types-of-stroke/hemorrhagic-strokes-bleeds

Frequently Asked Questions

While some studies show that aspirin use alone is not associated with a major increased risk of intracerebral hemorrhage (ICH), the risk can increase, particularly when it's taken in combination with other antiplatelet drugs or anticoagulants [1.3.5, 1.3.4].

Studies show that amphetamine abuse is associated with the highest risk, with abusers having nearly a 5-times greater odds of hemorrhagic stroke compared to non-users. Cocaine also carries a significant risk, more than doubling the odds [1.5.1].

These stimulant drugs cause a sympathetic surge, leading to a sudden and severe increase in blood pressure (hypertensive crisis) and constriction of blood vessels (vasospasm). This intense pressure can rupture a blood vessel in the brain [1.2.4, 1.2.2].

For many patients with conditions like atrial fibrillation, anticoagulants are highly effective and life-saving medications for preventing ischemic strokes [1.3.1]. However, they do carry an infrequent but serious risk of hemorrhage that requires careful management and monitoring by a doctor [1.3.1, 1.3.5].

While the individual risk is considered small, some studies have found an association between antidepressant use and intracranial hemorrhage, especially when used in combination with NSAIDs like ibuprofen [1.3.3].

A hemorrhagic stroke is caused by bleeding within or around the brain from a ruptured blood vessel. An ischemic stroke, which is more common, is caused by a blood clot blocking an artery that supplies blood to the brain [1.2.1].

Symptoms appear suddenly and can include a severe headache, unilateral numbness or weakness in the face, arm, or leg, acute confusion, difficulty speaking, vision problems, dizziness, loss of balance, nausea, and vomiting [1.2.1].