Minimum Headache Duration Prompting Subarachnoid Hemorrhage Workup

Headache related to subarachnoid hemorrhage (SAH) disappears within 48 hours in 1 of 10 patients who are neurologically intact and have used analgesics, according to a study published in the Journal of the Neurological Sciences.¹

SAH, a potentially dangerous cause of headache, must be ruled out in patients with acute onset of severe headache.¹ The European Stroke Organization and American Heart Association guidelines recommend that patients with severe acute headache should undergo diagnostic evaluation for SAH.^2,3 However, the minimum duration of headache for which SAH should be considered has not been established. As a result, clinicians may choose to forego an SAH workup in patients whose headaches disappear quickly.¹

Researchers sought to determine the minimal duration and clinical course of SAH-related headache within the first 48 hours after headache onset, based on observations from a database of patients with confirmed SAH.¹

A total of 106 patients with a normal level of consciousness and no focal neurological deficits was included in this study. Aneurysmal SAH (58%) was the most common etiology, followed by perimesencephalic hemorrhage (31%). Nonaneurysmal SAH, SAH related to a dural fistula, and SAH from an arteriovenous malformation accounted for the remainder.¹

Headache severity was measured using the Numeric Rating Scale (NRS; range 0-10, with 0 = no pain and 10 = worst pain imaginable). All patients received pain medication for their headache.¹

Rates of headache resolution (NRS score = 0) were 1%, 6%, and 8% at 12, 24, and 48 hours, respectively. The shortest amount of time between headache onset and pain disappearance was 10 hours in a patient with aneurysmal SAH who had received acetaminophen and tramadol 2.5 hours after headache onset.¹

“Almost complete disappearance of pain” (NRS score <3) was achieved in 7%, 14%, and 21% patients at 12, 24, and 48 hours, respectively. The minimum duration between headache onset and NRS <3 was 6 hours in patients with aneurysmal SAH.¹

Headache from perimesencephalic hemorrhage, the second most common cause of severe acute headache in this study, took a minimum of 14.5 hours to resolve completely (NRS = 0) and 9.75 hours to reach NRS <3.¹

“In conclusion, headache duration in patients with SAH using analgesics can be very short. A diagnostic work-up for SAH is also needed in patients using analgesics in whom headache has disappeared after 10h,” the researchers wrote.¹

References

1. Čomić H, Rinkel GJE, Vergouwen MDI. The initial time-course of headache in patients with spontaneous subarachnoid hemorrhage. J Neurol Sci. 2017;379:55-57.
2. Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G; European Stroke Organization. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis. 2013;35(2):93-112.
3. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-1737.