Treatment of headache in aneurysmal subarachnoid hemorrhage: Multimodal approach

Abstract

Sudden severe headache is a cardinal symptom and the most common complaint amongst patients presenting with aneurysmal subarachnoid hemorrhage. The multifactorial etiology of these headaches makes pharmacotherapy problematic. Current aneurysmal subarachnoid hemorrhage guidelines have limited or no recommendations for headache treatment. Our institution utilizes a multimodal pharmacotherapy protocol in the management of aneurysmal subarachnoid hemorrhage headache. The purpose of this study was to evaluate the efficacy of the current aneurysmal subarachnoid hemorrhage headache treatment approach at our institution. This was a retrospective cohort study of patients presenting with aneurysmal subarachnoid hemorrhage. A multimodal aneurysmal subarachnoid hemorrhage headache treatment protocol was implemented in February 2014. After an eight-month washout period, patients treated between September 2014 and November 2017 represented the study cohort. Data collected included severity of aneurysmal subarachnoid hemorrhage and headache, interventions to secure the aneurysm, pain score response related to specific analgesic administered, and discharge status. Multivariate analysis and linear regression were used to identify predictors of treatment efficacy. A total of 249 patients were identified in the study cohort. The majority of patients were female (61.4%) with a median age of 54 years (±12.5), median Hunt and Hess score of 2 (interquartile range 2–3), and mean length of hospitalization of 15.2 days. Magnesium infusion had the largest reduction in mean pain score compared to baseline pain score (−0.75; p = 0.0002). In this retrospective cohort study involving patients presenting with headache secondary to aneurysmal subarachnoid hemorrhage, no agent resulted in a clinically significant improvement on headache pain scores.

Keywords

• Analgesia
• Aneurysm
• Headache
• Magnesium
• Pain
• Subarachnoid hemorrhage