diff --git a/clang-tools-extra/clangd/ParsedAST.cpp b/clang-tools-extra/clangd/ParsedAST.cpp
--- a/clang-tools-extra/clangd/ParsedAST.cpp
+++ b/clang-tools-extra/clangd/ParsedAST.cpp
@@ -605,16 +605,15 @@
   // Copy over the macros in the preamble region of the main file, and combine
   // with non-preamble macros below.
   MainFileMacros Macros;
-  if (Preamble)
-    Macros = Preamble->Macros;
+  std::vector<PragmaMark> Marks;
+  if (Preamble) {
+    Macros = Patch->mainFileMacros();
+    Marks = Patch->marks();
+  }
   Clang->getPreprocessor().addPPCallbacks(
       std::make_unique<CollectMainFileMacros>(Clang->getSourceManager(),
                                               Macros));
 
-  std::vector<PragmaMark> Marks;
-  // FIXME: We need to patch the marks for stale preambles.
-  if (Preamble)
-    Marks = Preamble->Marks;
   Clang->getPreprocessor().addPPCallbacks(
       collectPragmaMarksCallback(Clang->getSourceManager(), Marks));
 
diff --git a/clang-tools-extra/clangd/Preamble.h b/clang-tools-extra/clangd/Preamble.h
--- a/clang-tools-extra/clangd/Preamble.h
+++ b/clang-tools-extra/clangd/Preamble.h
@@ -163,6 +163,9 @@
 
   static constexpr llvm::StringLiteral HeaderName = "__preamble_patch__.h";
 
+  llvm::ArrayRef<PragmaMark> marks() const;
+  MainFileMacros mainFileMacros() const;
+
 private:
   static PreamblePatch create(llvm::StringRef FileName,
                               const ParseInputs &Modified,
@@ -178,6 +181,7 @@
   // Diags that were attached to a line preserved in Modified contents.
   std::vector<Diag> PatchedDiags;
   PreambleBounds ModifiedBounds = {0, false};
+  const PreambleData *Baseline = nullptr;
 };
 
 } // namespace clangd
diff --git a/clang-tools-extra/clangd/Preamble.cpp b/clang-tools-extra/clangd/Preamble.cpp
--- a/clang-tools-extra/clangd/Preamble.cpp
+++ b/clang-tools-extra/clangd/Preamble.cpp
@@ -7,6 +7,7 @@
 //===----------------------------------------------------------------------===//
 
 #include "Preamble.h"
+#include "CollectMacros.h"
 #include "Compiler.h"
 #include "Config.h"
 #include "Diagnostics.h"
@@ -765,6 +766,7 @@
     return PreamblePatch::unmodified(Baseline);
 
   PreamblePatch PP;
+  PP.Baseline = &Baseline;
   // This shouldn't coincide with any real file name.
   llvm::SmallString<128> PatchName;
   llvm::sys::path::append(PatchName, llvm::sys::path::parent_path(FileName),
@@ -886,6 +888,7 @@
 
 PreamblePatch PreamblePatch::unmodified(const PreambleData &Preamble) {
   PreamblePatch PP;
+  PP.Baseline = &Preamble;
   PP.PreambleIncludes = Preamble.Includes.MainFileIncludes;
   PP.ModifiedBounds = Preamble.Preamble.getBounds();
   PP.PatchedDiags = Preamble.Diags;
@@ -896,5 +899,18 @@
   return PatchContents.empty() ||
          Config::current().Diagnostics.AllowStalePreamble;
 }
+llvm::ArrayRef<PragmaMark> PreamblePatch::marks() const {
+  if (PatchContents.empty())
+    return Baseline->Marks;
+  // FIXME: Patch pragma marks.
+  return {};
+}
+
+MainFileMacros PreamblePatch::mainFileMacros() const {
+  if (PatchContents.empty())
+    return Baseline->Macros;
+  // FIXME: Patch main file macros.
+  return MainFileMacros();
+}
 } // namespace clangd
 } // namespace clang
diff --git a/clang-tools-extra/clangd/unittests/PreambleTests.cpp b/clang-tools-extra/clangd/unittests/PreambleTests.cpp
--- a/clang-tools-extra/clangd/unittests/PreambleTests.cpp
+++ b/clang-tools-extra/clangd/unittests/PreambleTests.cpp
@@ -19,6 +19,7 @@
 #include "TestFS.h"
 #include "TestTU.h"
 #include "XRefs.h"
+#include "support/Context.h"
 #include "clang/Basic/SourceManager.h"
 #include "clang/Format/Format.h"
 #include "clang/Frontend/FrontendActions.h"
@@ -36,6 +37,7 @@
 #include <memory>
 #include <optional>
 #include <string>
+#include <utility>
 #include <vector>
 
 using testing::AllOf;
@@ -826,6 +828,35 @@
     EXPECT_THAT(*AST->getDiagnostics(), IsEmpty());
   }
 }
+
+TEST(PreamblePatch, MacroAndMarkHandling) {
+  Config Cfg;
+  Cfg.Diagnostics.AllowStalePreamble = true;
+  WithContextValue WithCfg(Config::Key, std::move(Cfg));
+
+  {
+    Annotations Code(R"cpp(
+#ifndef FOO
+#define FOO
+// Some comments
+#pragma mark XX
+#define BAR
+
+#endif)cpp");
+    Annotations NewCode(R"cpp(
+#ifndef FOO
+#define FOO
+#define BAR
+#pragma mark XX
+
+#endif)cpp");
+    auto AST = createPatchedAST(Code.code(), NewCode.code());
+    // FIXME: Macros and marks have locations that need to be patched.
+    EXPECT_THAT(AST->getMacros().Names, IsEmpty());
+    EXPECT_THAT(AST->getMarks(), IsEmpty());
+  }
+}
+
 } // namespace
 } // namespace clangd
 } // namespace clang