The course of headache in patients with moderate to severe headache due to aneurismal subarachnoid hemorrhage

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SCIENCE
The course of headache in patients with moderate to severe headache due to aneurismal subarachnoid hemorrhage
Key Take-Away: 

The course of headache in patients with aSAH (aneurismal subarachnoid hemorrhage) continuously improved during the 12 months of follow up. 

One of the most frequent symptoms of aSAH is the sudden onset of a severe headache. Previously, studies that addressed headache received little attention as; ultimately, achieving a good clinical outcome is of higher importance than headache improvement. However, headache affects the quality of life. 

ABSTRACT: 
Background: 

One of the most frequent symptoms of aSAH is the sudden onset of a severe headache. Previously, studies that addressed headache received little attention as; ultimately, achieving a good clinical outcome is of higher importance than headache improvement. However, headache affects the quality of life.

Patients who have undergone neurological surgeries refer to headache as the most debilitating symptom, irrespective of other postoperative complications.Recently, clinical outcomes of aSAH have improved, especially in patients with initially good clinical grade. Persistent headache (rather than other mild neurological symptoms after treatment) has received more attention due to its potential impact on the quality of life.

Rationale behind research

Little is known about the long term course of headache in patients with aSAH. Therefore, it is important to know more about the course of headache after aSAH, especially in patients without severe neurological deficit from aSAH.

  • Objective

To evaluate the course of headache in patients who had been treated for aSAH and to identify its predisposing factors

Methods: 

 

NOTE: This was a retrospective cross-sectional study

Study outcomes

  • Numeric Rating Score (NRS):  The NRS is an 11-point numeric scale for rating pain intensity. This quantitative scale ranges from 0-10, with 0 meaning “no headache at all” and 10 meaning “the worst possible headache.” This 11-point scale has been previously applied to headache assessment. We defined NRS scores of 1-3, 4 -6, and 7-10 as mild, moderate, and severe headaches. These scores were administered every 8 hours (3 times/day) during hospitalization and twice per every visit of the outpatient department.
  • Other variables related to NRS changes, included age, gender, initial Fisher grade, hypertension, diabetes, dyslipidemia, smoking, alcohol, previous stroke, previous headache treated with medication, hydrocephalus, external ventricular drainage (EVD), shunt, symptomatic vasospasm, treatment modality (microsurgery or EVT), procedure-related complication, clinical outcome, aneurysm location and size and neck diameter.
  • Time points
  • NRS Scores: Baseline, upon discharge and at 1 month, 3 months, 6 months and 12 months after discharge.
Results: 

 

Outcomes

  • Of 217 patients with moderate to severe headache on admission, 182 (83.9%) experienced headache improvement (NRS score ≤ 30) upon discharge, 204 (94.0%) improved after 1 month, 208 (95.9%) after 3 months, 213 (98.2%) after 6 months and 215 (99.1%) after 12 months of follow-up.
  • The average NRS scores were, chronologically 6.9, 2.0, 1.0, 0.6, 0.5 and 0.4 on admission, discharged 1-month, 3-months, 6-months and 12-months of follow-up, respectively. The NRS scores at discharge were significantly lower than those on admission (P < .001).
  • The follow-up NRS scores were significantly lower than those at discharge at every follow-up time point (P < .001). The follow-up NRS scores decreased continuously during the 12-month follow-up
  • The independent predisposing factors for headache improvement included previous stroke (odds ratio [OR] = 0.141; 95% CI 0.051-0.381; P < .001), previous headache treated with medication (OR = 0.079; 95% CI 0.010-0.518; P = .008) and endovascular treatment (EVT; OR = 2.531; 95% CI 1.141-5.912; P = .026)
  • EVT and symptomatic vasospasm were independently associated with a decrease of NRS in the follow-up periods

 

Conclusion: 

Patients with aSAH who initially had moderate to severe headache experienced significant headache improvement at discharge with continuously decreasing NRS scores over 12 months of follow-up. 

According to literature, most headaches attributed to aSAH persist for several days. In addition, there are no established data for long-term follow-ups of headaches in patients with aSAH. Magalhães et al reported that the average duration of headache associated with aSAH was 12.5 days. Only 3 of 97 patients had persistent headache. However, headaches in aSAH patients may not be attributable to aSAH itself; other possible contributing factors to headache development include increased intracranial pressure, therapeutic procedure-related factors (postoperative state), or psychiatric factors such as anxiety or depression

Headache. 2015 Jul-Aug;55(7):992-9
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