Severe headache is a hallmark of aneurysmal subarachnoid hemorrhage (aSAH), plaguing up to 90% of patients during hospitalization. Despite the high prevalence of this debilitating symptom, little is known regarding the progression of headache over time as well as management strategies. We present data from a cohort of patients from a large tertiary care center with aSAH, specifically evaluating daily headache scores and analgesic administration.

This is a single center retrospective review of patients admitted with Hunt and Hess (HH) Grade 3 or less aSAH between 2012-2013 and 2016-2019. Patients with headaches who were able to verbally provide their pain level during hospitalization were included.

71 patients (HH1, 30; HH2, 15; HH3, 26) met inclusion criteria. Mean age at time of presentation was 54±16 years, 72.8% were female (n=51) and 77.5% were Caucasian (n=55). Average hospital length of stay was 12±6 days. Average maximal daily headache score was 6.1±2.3 (95% CI: 5.6, 6.7) with a mean daily headache of 2.0±1.7. (95% CI: 1.6, 2.4). Average daily analgesic use (mean±SD, [95% CI]) included 17.4±22.3mg (12.1, 22.7) for oral morphine equivalents, 1033±839mg (834, 1232) for acetaminophen, and 3.5±2 (2.9, 4.0) tablets of acetaminophen/butalbital/caffeine. Incidence of severe headache (7-10/10) had a bimodal maxima of 73% on post-bleeds day 0 and 10. After day 10, incidence of severe headaches steadily declined. The incidence of severe headaches did not correlate with average oral morphine equivalent (rho=-0.18, p=0.51).

Headaches following aSAH are persistent and severe during the first 10 days post-hemorrhage with decline in severity thereafter. Management during this acute period heavily relies on use of opiates and acetaminophen, with incomplete alleviation of pain despite high dosing of analgesics. Our data from this large cohort evaluating headache after aSAH indicate that headache is poorly controlled, and opiate-sparing, innovative management strategies are urgently needed.