Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

Abstract

Background: Severe headaches are common after subarachnoid hemorrhage (SAH). Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting SAH patients during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH.Methods: We conducted an international cross-sectional study through a 37-question web-based survey distributed to members of 5 professional societies relevant to intensive and neurocritical care from 11/2021-1/2022. Responses were characterized through descriptive analyses; Fisher's exact test was used to test associations.Results: Of 516 responses, 329/497 (66%) were from North America and 121/497 (24%) from Europe. 379/435 (87%) reported headache as major management concern for SAH patients. Intensive-care-teams were primarily responsible for analgesia during hospitalization (249/435, 57%), while responsibility shifted to neurosurgery at discharge (233/501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%) and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective, by 169/433 (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96/433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303/381, 80%), followed by opioids (175/381 [46%]), and antiseizure medications (173/381, 45%). Opioids during hospitalization were signi cantly more prescribed by intensivists, by providers managing higher numbers of SAH patients, and in Europe. At discharge, opioids were more frequently prescribed in North America. 299/435 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers, and inpatient versus discharge were found.Conclusions: Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in utilization and in perception of e cacy, with no reported change in prescription patterns for opioids for most providers despite the signi cant drawbacks of opioids.Responsibility for analgesia shifts between hospitalization and discharge. International and providerrelated differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

Safety and efficacy of peripheral nerve blocks to treat refractory headaches after aneurysmal subarachnoid hemorrhage – A pilot observational study

“…Despite these improvements, and a high prevalence of HASH, research in this area is lacking including, phenotypic HASH data, efficacious treatment options and treatment guidelines for providers. In the first cross-sectional worldwide study on HASH, Maciel et al reported that HASH is recognized as a major clinical concern in 87% of providers, opioids are perceived as the most effective analgesic modality, and nearly half the providers prescribe opioids at discharge ( 9 ). This is problematic, given the drawbacks of opioid usage in the acute phase of injury following aSAH, as well as longer term, given the high potential for addiction and contribution to the ongoing opioid epidemic.…”

“…The use of CGRP-modulating therapies in acute conditions such as traumatic brain injury and SAH continues to be explored ( 29 , 30 ). Data on the effectiveness and safety of NSAIDs are limited in HASH, with over 50% of providers stating they rarely or never used NSAIDS in this setting ( 9 ), likely due to perceived risk of worsening bleeding. Systemic dexamethasone is often reserved for refractory cases due to systemic adverse effects of hyperglycemia, reduced sleep, and possible interference with wound healing.…”

“…All patients were followed up at 1 week after enrollment, so we were able to show there was still benefit at that time point. Importantly, there is growing research that patients with HASH follow discrete pain trajectories ( 10 ), and pain trajectories can predict generation of chronic pain ( 9 , 33 ). In our preliminary study, we found that PNB appeared to alter this trajectory immediately after administration, therefore it is plausible that it may alter and development of chronic HASH in some patients.…”

“…Each modality is ineffective on its own, and many have significant drawbacks including clouding of neurological status, respiratory suppression and dose-dependent hepatotoxicity or nephrotoxicity. Despite high prevalence and potential deleterious effects of HASH, there is a lack of evidence-based treatment modalities for this disease with only 9% of providers indicating use of a standardized approach for HASH management, for which opioids remain the mainstay ( 9 ). Pain trajectories following aSAH are associated with continued opioid use at outpatient follow up ( 10 ), which contributes to the ongoing opioid epidemic.…”

The Prevalence and Factors Associated with the Prescription of Opioids for Head/Neck Pain after Elective Craniotomy for Tumor Resection/Vascular Repair: A Retrospective Cohort Study

“…They found that 70% of opioid-naive patients with below-average opioid use during their hospital stay and low pain scores on discharge still received an opioid prescription upon discharge [ 21 ]. Since there is no institutional protocol with respect to the prescribing OME, the dose prescribed may very well be influenced by the subjective opinion of the treating physician, a finding observed in the neurocritical care setting [ 22 ]. Our study finds that opioid use is common in the postoperative period [ 23 ].…”