Pain treatment after aneurysmal subarachnoid hemorrhage
Many of the commonly used analgesics for headache are problematic in the acute SAH patient. Aspirin and other nonsteroidal antiinflammatory drugs (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 corticosteroids) 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) 1).
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.
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 2)