Most Strokes Give a Warning. Most of Us Miss It.

Four years ago, my father picked my kids up from school. When he got home, he lay down and said he wasn’t feeling well. My mom wanted to call the paramedics right away. He told her not to. It was probably something he ate.

Two days later, she convinced him to go for a check-up anyway.

The doctor said he’d had a heart attack. He was admitted immediately. When they ran the full tests, they found that three out of four of his heart’s arteries were 90% blocked. A few days later, he had a triple bypass surgery.

My mom’s insistence — two days late — saved his life. He just celebrated his 80th birthday in April.

I think about this every time I write about warning signs. Not because heart attacks and strokes are the same thing, but because the behavior is identical. The symptom that feels minor. The explanation that sounds reasonable. The decision to wait and see. That waiting is where the damage happens — in both.

May is Stroke Awareness Month. Strokes are the fifth leading cause of death in the United States and a leading cause of long-term disability. Up to 80% are preventable. And many come with warnings we explain away as tiredness, a stiff neck, a strange morning.

This is about what those warnings look like — and what to do the moment you see them.

F.A.S.T. — The Four-Letter Word You Need to Know Cold

You may have heard the acronym before. But there’s a difference between having heard it and knowing it well enough to use it in a moment of fear, when your hands are shaking and you’re not sure what’s happening.

F — Face drooping. Ask the person to smile. Is one side of the face numb or drooping? An uneven smile is a red flag.

A — Arm weakness. Ask them to raise both arms. Does one arm drift downward or feel weak?

S — Speech difficulty. Is the speech slurred? Is the person unable to speak or hard to understand? Ask them to repeat a simple sentence: “The sky is blue.” Listen carefully.

T — Time to call 911. If you see any one of these signs, call immediately. Don’t wait to see if it passes.

Here’s what most people don’t realize: stroke treatments — particularly clot-busting medications — have a narrow window to work. Every minute of delay causes roughly 1.9 million neurons to die. The phrase doctors use is “time is brain.” Calling 911 at the first sign, even if you’re not sure, is the right call every time. A false alarm is survivable. A delayed stroke often isn’t.

Some hospitals now use a longer version called BE-FAST, which adds two earlier signs:

B — Balance. Sudden loss of balance or coordination, often with dizziness or trouble walking. This one gets missed frequently because it can look like a stumble.

E — Eyes. Sudden blurred or double vision in one or both eyes, or vision loss on one side.

These two symptoms often appear before the classic face-arm-speech signs. If someone suddenly can’t walk straight or says their vision went strange, BE-FAST.

While you wait for 911: Note the exact time the symptoms started — the medical team will ask, and it determines which treatments are available. Don’t give the person food or water. Don’t let them lie down to “rest it off.” Keep them calm and awake. If they’re unconscious and not breathing, CPR is appropriate, but most stroke patients are conscious.

Print F.A.S.T. out. Put it on your fridge. Teach it to whoever lives with you or checks on you regularly.

Blood Pressure: The Warning Sign You Can’t Feel

High blood pressure is the single biggest modifiable risk factor for stroke. And it’s called the “silent killer” for a reason — it causes no pain, no obvious symptoms, no alarm bells.

The risk isn’t subtle. Adults with high blood pressure are four to six times more likely to have a stroke than those with normal readings. And yet surveys consistently show that around half of adults with hypertension either don’t know they have it, or aren’t managing it effectively.

A reading of 130/80 mmHg or above is now considered high. If you haven’t checked yours recently, that’s the place to start. Many pharmacies have free machines. Your doctor can check it in seconds. But the most useful data is what your blood pressure does across time — not in a single clinical visit when you might be tense and rushed.

A home blood pressure monitor costs $25 to $40 at most pharmacies and gives you a much clearer picture. Check it at the same time each morning, before coffee or medication, after a few minutes of sitting quietly. If your readings are consistently above 130/80, bring those numbers to your doctor.

If you’ve already been diagnosed, the unsexy truth is this: taking your medication consistently matters more than almost anything else. Blood pressure doesn’t spike on a schedule. Skipping doses — even occasionally — leaves gaps in your protection.

Beyond medication, the changes that move the needle most aren’t dramatic. Reducing sodium to under 1,500 mg per day (roughly half a teaspoon of salt) can lower systolic pressure by 5 to 6 points. That number adds up fast when you realize how much sodium hides in bread, canned soup, deli meat, and restaurant food — not just the salt shaker. Potassium works in the opposite direction: it helps your body excrete sodium. Bananas get all the credit, but avocados, sweet potatoes, and white beans are actually higher in potassium and easy to build into regular meals.

Regular moderate movement adds another 4 to 9 points off systolic pressure. Alcohol raises it — more than one drink per day for women, more than two for men, pushes blood pressure up consistently. And chronic poor sleep, which we’ll get to in a moment, is one of the most underappreciated drivers of elevated blood pressure in older adults.

These numbers aren’t huge individually. Together, they can shift you out of the high-risk zone without a prescription change.

The Stroke Risk Hidden in Your Heart

This one doesn’t get enough attention.

Atrial fibrillation — a-fib — is an irregular heart rhythm that affects an estimated 9% of adults over 65. That number climbs to 1 in 4 by age 80. And a-fib increases stroke risk by five times.

Here’s why: when the upper chambers of the heart beat chaotically instead of rhythmically, blood can pool and form clots. If one of those clots travels to the brain, the result is a stroke. Strokes caused by a-fib tend to be more severe than other types because the clots are larger.

The frustrating part is that a-fib is often silent. Some people feel it as palpitations — a fluttering, racing, or irregular sensation in the chest. Others feel unusual fatigue, shortness of breath, or lightheadedness. But many people have no symptoms at all and only discover it during a routine EKG.

If you’ve never had an EKG, ask your doctor at your next visit. If you have been diagnosed with a-fib, the most important conversation to have is about anticoagulation — blood-thinning medications that dramatically reduce clot formation and stroke risk. Many people with a-fib are candidates for these medications but haven’t been put on them, or stopped taking them because they were worried about bleeding risk. That’s a conversation worth having openly with your doctor, not a decision to make on your own.

Sleep: The Stroke Risk Nobody Talks About

This one surprises people.

Poor sleep isn’t just exhausting. It’s a genuine stroke risk factor — and it works through several pathways at once.

Obstructive sleep apnea, where breathing repeatedly stops during sleep, affects an estimated 20 to 30% of older adults. Many don’t know they have it. During apnea episodes, oxygen levels drop and blood pressure spikes repeatedly throughout the night. The cardiovascular system is under stress for hours at a time, night after night. Over time, this damages blood vessel walls and accelerates the conditions that lead to stroke. People with untreated sleep apnea have roughly double the stroke risk of those without it.

The warning signs to watch for — in yourself or a partner — include loud snoring, gasping or choking sounds during sleep, waking up with headaches or a dry mouth, and feeling unrested despite a full night in bed. Daytime drowsiness that seems out of proportion to how much you slept is another flag. If any of that sounds familiar, mention it to your doctor. A sleep study can confirm it, and treatment (usually a CPAP device) significantly reduces stroke risk, often within months.

Even without apnea, sleep duration matters. Consistently sleeping fewer than six hours per night is associated with a significantly higher stroke risk. What’s less well known is that sleeping more than nine hours regularly is also associated with elevated risk — partly because excessive sleep time can be a sign of underlying cardiovascular or inflammatory issues, not just rest.

The sweet spot for most older adults is seven to eight hours. Quality matters as much as quantity. Fragmented sleep — waking frequently through the night — has its own inflammatory effects, even when total hours look adequate on paper.

A few things that consistently disrupt sleep in older adults: late-day caffeine (its half-life is about 5 to 7 hours, so a 3 p.m. coffee is still half-active at 9 p.m.), irregular bedtimes, and sleeping in a room that’s too warm. Body temperature needs to drop slightly to initiate deep sleep, which is why a cooler bedroom (around 65 to 68 degrees Fahrenheit) helps. Long naps are also worth watching — naps over 90 minutes can interfere with nighttime sleep architecture for some older adults, while a 20-minute rest is usually neutral.

If sleep problems are ongoing, the most effective treatment isn’t a stronger sleep aid. It’s a structured approach called CBT-I (Cognitive Behavioral Therapy for Insomnia), which has stronger long-term outcomes than medication and is available through therapists, apps, and sleep clinics.

Your Questions Answered

I had a brief episode where my face felt strange but it passed in minutes. Should I have called 911?

Yes. What you’re describing sounds like a TIA — a transient ischemic attack, sometimes called a “mini-stroke.” It’s a medical emergency, not a near-miss. Up to 10% of people who have a TIA will have a full stroke within 48 hours. “It passed” doesn’t mean “it’s over.” Even if you’re reading this days later, call your doctor today.

My blood pressure is controlled with medication. Am I still at risk?

Lower risk than without treatment, but not zero. Blood pressure is one factor among several. Atrial fibrillation, diabetes, smoking, physical inactivity, and sleep apnea all independently raise stroke risk. Controlled blood pressure is an important piece, not the whole picture.

I’ve been taking a daily aspirin for years. Doesn’t that protect me?

It depends. Aspirin reduces clot formation and is appropriate for some people who’ve already had a stroke or heart attack. But for people who haven’t, current guidelines no longer recommend daily aspirin for most adults over 60 — the bleeding risk can outweigh the benefit. If you’re taking aspirin preventively and haven’t revisited that decision with your doctor recently, it’s worth bringing up at your next visit.

Does stress cause strokes?

Chronic stress contributes to high blood pressure, poor sleep, and systemic inflammation — all of which increase stroke risk over time. A single stressful event doesn’t cause a stroke on its own, but the body’s prolonged stress response creates the conditions that raise the odds. Managing stress isn’t soft advice. It’s cardiovascular advice.

Are stroke symptoms different in women?

The core symptoms — face drooping, arm weakness, speech difficulty — are the same. But women are more likely than men to experience additional symptoms that often get dismissed: sudden severe headache, confusion, nausea, hiccups, and general weakness or fatigue. Because these symptoms overlap with other conditions, strokes in women are sometimes recognized later. If something feels suddenly and severely wrong, trust that instinct.

The One Thing to Do Today

If there’s one practical step to take this week: check your blood pressure. And while you’re at it, teach F.A.S.T. to whoever spends the most time with you.

Strokes are devastating partly because they often strike people who didn’t know they were at risk — or who saw a warning and waited. You don’t have to be one of those stories.