====== Pain treatment after aneurysmal subarachnoid hemorrhage ======

Many of the commonly used [[analgesic]]s for [[headache]] are problematic in the acute SAH patient. [[Aspirin]] and other [[nonsteroidal antiinflammatory drug]]s (NSAIDs) can inhibit platelet aggregation, thereby exacerbating bleeding after SAH. [[Opioid]] medications such as [[oxycodone]] or [[morphine]] can cause [[sedation]], which may confound the neurologic exam in these vulnerable patients. Alternative, non-opioid agents such as [[tramadol]] also cause sedation and may reduce seizure threshold.

Combination agents such as [[acetaminophen]]/butalbital/[[caffeine]] (Fioricet) may have various adverse effects and variable durations of action (eg.caffeine can cause cerebral vasoconstriction, but has a short half-life;Butalbital causes sedation and has a very prolonged half-life).

Other agents such as [[magnesium]] and [[dexamethasone]] have also been used forSAH patients. Magnesium may cause hypotension with rapidadministration, while dexamethasone (like all [[corticosteroid]]s) is associated with a number of adverse effects (most concerning acutely are [[hyperglycemia]] and [[agitation]]). Clinicians are often left with few [[evidence]]-based options for treating [[headache]], the most prevalent of which is [[acetaminophen]] (which, in doses N 4 g/day may cause hepatic dysfunction)
((https://www.sciencedirect.com/science/article/pii/S2214751914000334)).
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Rasouli J, Watson C, Yaeger K, Ladner T, Kellner C, Dangayach NS. Pain control
after aneurysmal subarachnoid hemorrhage: A contemporary literature review. J
Clin Neurosci. 2019 Aug 7. pii: S0967-5868(18)32217-3. doi:
10.1016/j.jocn.2019.07.057. [Epub ahead of print] Review. PubMed PMID: 31401000.
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Subarachnoid haemorrhage (SAH) is usually associated with severe headache, whereas the options of pharmacological analgesia are restricted. Acupuncture is a promising method in treatment of headaches associated with meningeal sensitivity or irritation, such as migraine or post-dural puncture headache.

Dietzel et al. report on 3 patients, who suffered severe headache due to aneurysmal SAH, and received acupuncture when pharmacological measures were exhausted. After acupuncture treatment all patients reported at least 50% pain reduction and could stop or reduce analgesics without side effects.

Acupuncture may be an effective pain treatment method in patients suffering from headache due to SAH. Randomized trials using acupuncture as an add-on to standard analgesic therapy would help evaluate the role of acupuncture for this purpose
((Dietzel J, Eck T, Usichenko T. Treating Therapy-Resistant Headache After
Aneurysmal Subarachnoid Hemorrhage with Acupuncture. Neurocrit Care. 2019 Apr 29.
doi: 10.1007/s12028-019-00718-3. [Epub ahead of print] PubMed PMID: 31037638.
))