Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies

Abstract

Objective This narrative review of the literature concerns persistent headache attributed to past non‐traumatic subarachnoid hemorrhage (SAH), based off demographic and clinical features, what are pathophysiologic mechanisms by which these headaches occur, which medical and interventional treatments have the most evidence for pain alleviation, and what pre‐clinical evidence is there for emerging treatments for these patients. Background Following initial stabilization and treatment of spontaneous SAH, most commonly due to aneurysmal rupture, headache in the immediate inpatient setting and persisting after discharge are an important cause of morbidity. These headaches often receive heterogenous treatment of uncertain efficacy, and the risk factors and pathophysiology of their development has received little study. Methods A narrative review of current literature discussing post‐SAH headache was conducted using a literature search in PubMed with search term combinations including “post subarachnoid hemorrhage pain”, “subarachnoid hemorrhage headache”, and “post subarachnoid hemorrhage headache”. Clinical studies mentioning headache after SAH and/or treatment in the abstract/title were included through March, 2022. Results and Conclusion Post‐SAH headaches are shown to decrease quality of life, have a multi‐modal pathophysiology in their occurrence, and only a select few medications (reviewed herein) have been demonstrated to have efficacy in alleviation of these headaches, while also harboring possible risks including vasospasm and re‐bleeding. An effective treatment paradigm of these headaches will include trials of evidence‐based therapeutics, rapid reduction of opioid medications if not effective, and consideration of multi‐modal pain control strategies including nerve blocks.

Incidence of intra-procedural complications according to the timing of endovascular treatment in ruptured intracranial aneurysms

“…Neuroinflammation seems to have a crucial role in aneurysm formation and rupture and seems to be involved in vasospasm, hydrocephalus, and headache in patients with SAH (34,35). It would be interesting to analyze, in a large prospective study, whether a higher level of neuroinflammation is associated with a higher risk of intra-procedural complications during endovascular treatment.…”

Virtual issue: Recent advances in the headache–cerebrovascular disease relationship

“…With the exception of a 2020 narrative review of the relationship of migraine and ischemic stroke, 1 the papers were published in 2021, [3][4][5] 2022, [6][7][8][9][10][11] and early 2023. [12][13][14][15][16] The first section focuses on populations of individuals with migraine (stratified by headache frequency) 3 and with aura or aura-like events, 4,5,9,12 detailing investigations of clinical characteristics and etiologies that may predispose to stroke.…”

“…[12][13][14][15][16] The first section focuses on populations of individuals with migraine (stratified by headache frequency) 3 and with aura or aura-like events, 4,5,9,12 detailing investigations of clinical characteristics and etiologies that may predispose to stroke. The second section includes papers examining the relationship of headache and CV events, including migraine as an ischemic stroke risk factor 1,6,16 and headache following aneurysmal subarachnoid hemorrhage 10,11 or cervicocerebral dissection. 14 Papers in the third section focus on cardiovascular risk in persons on migraine therapeutics, specifically triptans 7,8,13 for acute treatment and erenumab, 15 a fully human monoclonal antibody to the calcitonin gene-related peptide receptor, for migraine prevention.…”