diff --git a/clang-tools-extra/clangd/XRefs.cpp b/clang-tools-extra/clangd/XRefs.cpp
--- a/clang-tools-extra/clangd/XRefs.cpp
+++ b/clang-tools-extra/clangd/XRefs.cpp
@@ -756,8 +756,10 @@
 
   RefsRequest Req;
   if (Macro) {
-    // Handle references to macro.
-    if (auto MacroSID = getSymbolID(Macro->Name, Macro->IdentLoc, SM)) {
+    // Handle references to macro, we are using DefRange instead of IdentLoc as
+    // references are collected without #line directive mappings.
+    if (auto MacroSID =
+            getSymbolID(Macro->Name, Macro->DefRange.getBegin(), SM)) {
       // Collect macro references from main file.
       const auto &IDToRefs = AST.getMacros().MacroRefs;
       auto Refs = IDToRefs.find(*MacroSID);
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
@@ -14,12 +14,14 @@
 #include "SourceCode.h"
 #include "TestFS.h"
 #include "TestTU.h"
+#include "XRefs.h"
 #include "clang/Format/Format.h"
 #include "clang/Frontend/PrecompiledPreamble.h"
 #include "clang/Lex/PreprocessorOptions.h"
 #include "llvm/ADT/STLExtras.h"
 #include "llvm/ADT/StringExtras.h"
 #include "llvm/ADT/StringRef.h"
+#include "llvm/Support/Error.h"
 #include "llvm/Support/MemoryBuffer.h"
 #include "llvm/Support/VirtualFileSystem.h"
 #include "gmock/gmock.h"
@@ -31,6 +33,7 @@
 
 using testing::Contains;
 using testing::Field;
+using testing::Matcher;
 
 namespace clang {
 namespace clangd {
@@ -362,6 +365,55 @@
   }
 }
 
+TEST(PreamblePatchTest, RefsToMacros) {
+  struct {
+    llvm::StringLiteral Baseline;
+    llvm::StringLiteral Modified;
+  } Cases[] = {
+      // Newly added
+      {
+          "",
+          R"cpp(
+            #define ^FOO
+            ^[[FOO]])cpp",
+      },
+      // Moved around
+      {
+          "#define FOO",
+          R"cpp(
+            #define BAR
+            #define ^FOO
+            ^[[FOO]])cpp",
+      },
+      // Ref in preamble section
+      {
+          "",
+          R"cpp(
+            #define ^FOO
+            #undef ^FOO)cpp",
+      },
+  };
+
+  for (const auto &Case : Cases) {
+    Annotations Modified(Case.Modified);
+    auto AST = createPatchedAST("", Modified.code());
+    ASSERT_TRUE(AST);
+
+    const auto &SM = AST->getSourceManager();
+    std::vector<Matcher<Location>> ExpectedLocations;
+    for (const auto &R : Modified.ranges())
+      ExpectedLocations.push_back(Field(&Location::range, R));
+
+    for (const auto &P : Modified.points()) {
+      auto *MacroTok = AST->getTokens().spelledTokenAt(SM.getComposedLoc(
+          SM.getMainFileID(),
+          llvm::cantFail(positionToOffset(Modified.code(), P))));
+      ASSERT_TRUE(MacroTok);
+      EXPECT_THAT(findReferences(*AST, P, 0).References,
+                  testing::ElementsAreArray(ExpectedLocations));
+    }
+  }
+}
 } // namespace
 } // namespace clangd
 } // namespace clang