Treatment of headache in aneurysmal subarachnoid hemorrhage: Multimodal approach

Hile, Garrett; Cook, Aaron M.

doi:10.1016/j.inat.2020.100857

Cited by 14 publications

(13 citation statements)

References 12 publications

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“…This has potential therapeutic implications as standard pharmacological management such as acetaminophen ± opioids for post‐aSAH headache does not significantly improve the headache 12 . Additional therapies such as magnesium have been shown to reduce headache pain scores although the change was not clinically significant 13,14 . Migraine preventative treatments, including those which have been shown to influence CSD in migraine, may therefore offer superior analgesia for persistent headache following aSAH.…”

Section: Discussionmentioning

confidence: 99%

Duration and characteristics of persistent headache following aneurysmal subarachnoid hemorrhage

et al. 2022

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Objective To assess the long‐term frequency, prognosis, and phenotype of persistent headache following aneurysmal subarachnoid hemorrhage (aSAH). Background Very little is known about long‐term headache following aSAH with no studies looking beyond 3 years. Methods Retrospective analysis comparing aSAH cases to matched controls in the UK Biobank, a prospective cohort study. Headache frequency and phenotype were compared using group comparison tests. The relationship between headache frequency and time was assessed using correlation analysis. Results Headache was more frequent following aSAH (aSAH: 258/864 [29.9%] vs. controls: 666/3456 [19.3%], χ2 = 45.5, p < 0.001) at a median follow‐up of 7.5 years. Headache frequency decreased over time (RS = −0.71, p = 0.028), affecting 29/58 (50%) patients in the first year and reducing to 13/47 (28%) patients 10 years later. Headache frequency was not related to aSAH severity (z = 0.249, p = 0.803), treatment (z = 0.583, p = 0.560), or hydrocephalus (z = −1.244, p = 0.214). There was a consistently higher frequency of migrainous features following aSAH compared to controls, although this did not reach statistical significance. Conclusions Persistent headache is more frequent following aSAH compared to controls in the long term and the prevalence reduces gradually over time. The increased frequency of migrainous features suggests that selected patients with post‐aSAH headache may benefit from migraine treatment.

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Section: Discussionmentioning

confidence: 99%

Duration and characteristics of persistent headache following aneurysmal subarachnoid hemorrhage

et al. 2022

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“…Many centers have reported daily oral morphine equivalent ranging from 22mg to 63mg and commonly exceeding 400mg over the hospital stay even after introduction of opioid-sparing initiatives [4,5,22]. While our survey indicates that opioids were also perceived as the most effective analgesic strategy, prior data have shown that opioid analgesia is suboptimal and oftentimes fails to alleviate pain on the standard assessments in a meaningful way (i.e., reduction of pain scores by at least 2 points on the 11-point numeric rating scale) [4,14,23]. This nding of opioids performing suboptimally as an analgesic has also been found in migraine, where hydromorphone was inferior to prochlorperazine in a randomized clinical trial [24].…”

Section: Opioids In Post-sah Headache Managementmentioning

confidence: 96%

“…With post-SAH headache constituting the 4 th most common cause for 30-and 90-day readmissions, surpassed only by stroke, hydrocephalus, and sepsis [42], this practice constitutes a gap that may be worthwhile for a systematic and multidisciplinary approach. Second, the most commonly prescribed medication was acetaminophen, a medication likely not su cient in many instances [14], and opioids, with the drawbacks as discussed Last, there is a common shift in the prescribing provider from intensive care team during the inpatient stay to neurosurgical team at discharge. With 91% of respondents reporting no availability of an institutional protocol for managing headaches in this population, scarce data available to guide such management, and the shift in responsibility on transition to outpatient management, it is not surprising that overall dissatisfaction with headache management has been reported by patients during both inpatient and outpatient care [21].…”

Section: Alternative Analgesic Strategiesmentioning

confidence: 99%

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

et al. 2022

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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.

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Section: Alternative Analgesic Strategiesmentioning

confidence: 99%

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

Maciel¹,

Barlow²,

Gobinathan³

et al. 2022

Preprint

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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 significantly 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 efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

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Treatment of headache in aneurysmal subarachnoid hemorrhage: Multimodal approach

Cited by 14 publications

References 12 publications

Duration and characteristics of persistent headache following aneurysmal subarachnoid hemorrhage

Duration and characteristics of persistent headache following aneurysmal subarachnoid hemorrhage

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

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

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