Headache After SAH

Headache after SAH increases in intensity during first 7d after onset.

Mechanism:

  • factors that contribute to vasopasm may also lead to headache
  • chemical irritation of blood on meninges and subarachnoid space can cause pain
  • infiltration of immune cells, immune activation and inflammatory cytokines contributes to pain
  • alterations in brain perfusion from vasopasm may also be a factor

 

Treatment:

  • Fioricet largely ineffective, ?associated with early vasospasm
  • In SAH patients, elevated Mg levels associated with less severe headache, – IV magnesium therapy may provide relief for SAH patients?
    • Magnesium is a non-competitive antagonist of voltage-dependent calcium channels and NMDA receptor.  Blocking of NMDA receptor is involved in pain modulation – prevents induction of central pain sensitisation. 
    • The effect of magnesium on headache after SAH is unknown. 
    • Most studies use dose of 1-2G IV bolus, in the study referenced below, higher daily dose (16G MgSO4 for a sustained period – nonbolus) was given. 
    • Diarrhea is a common side effect.

 

AP41 cocktail:

  1. Fioricet 1 q4h
  2. tramadol 100 q6h
  3. valproate 500 IV q8h x3d
  4. metoclopramide 5-10mg q6h x 3d
  5. Mg 2G IV once

*monitor QT interval

 

References

Dorhout Mees, S., Bertens, D., van der Worp, H., Rinkel, G., & van den Bergh, W. (2009). Magnesium and headache after aneurysmal subarachnoid haemorrhage. Journal Of Neurology, Neurosurgery & Psychiatry81(5), 490-493. doi: 10.1136/jnnp.2009.181404

Swope, R., Glover, K., Gokun, Y., Fraser, J., & Cook, A. (2014). Evaluation of headache severity after aneurysmal subarachnoid hemorrhage. Interdisciplinary Neurosurgery1(4), 119-122. doi: 10.1016/j.inat.2014.07.003

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