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Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

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Abstract

Background

Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH.

Methods

We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher’s exact test was used to test associations.

Results

Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found.

Conclusions

Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

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Data availability

The data sets used and analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We thank the American Academy of Neurology, the European Society for Intensive Care Medicine, the Neuro Anesthesia and Critical Care Society, the Neurocritical Care Society, and the Society for Critical Care Medicine for their review of our survey, the thoughtful edit suggestions, and the distribution or posting through society websites and/or email notification.

Funding

This study was conducted without dedicated funding sources. CBM has received funding from the Claude D. Pepper Older Americans Independence Center and American Heart Association. BL-W is funded by National Institutes of Health grant R25 NS108939. LHM has received funding from the National Institutes of Health and the Department of Defense. GM is funded by the American Heart Association. GS is funded by National Institutes of Health grant R01AG070849. NAM is funded by the University of Maryland, Baltimore, Institute for Clinical and Translational Research Accelerated Translational Incubator Pilot Grant, a subaward from National Center for Advancing Translational Sciences grant 1UL1TR003098. KMB has received funding through the W. Martin Smith Award at the University of Florida.

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Authors and Affiliations

  1. Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA

    Carolina B. Maciel, Mounika Mukherjee Peethala, Katie Dickinson & Katharina M. Busl

  2. Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA

    Carolina B. Maciel, Brandon Lucke-Wold & Katharina M. Busl

  3. Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA

    Brooke Barlow

  4. Departments of Microbiology and Anthropology, University of Florida, Gainesville, FL, USA

    Arravintha Gobinathan

  5. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA

    Zaid Abu-Mowis

  6. Department of Emergency Medicine College of Medicine, Virginia Commonwealth University, Richmond, VA, USA

    Lisa H. Merck

  7. Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche di Bologna, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna, Italy

    Raffaele Aspide

  8. Department of Biostatistics, University of Florida, Gainesville, FL, USA

    Guanhong Miao & Guogen Shan

  9. Research Design and Data Coordinating Center, Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA

    Guogen Shan

  10. Department of Anesthesiology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy

    Federico Bilotta

  11. Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA

    Nicholas A. Morris

  12. School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy

    Giuseppe Citerio

  13. Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy

    Giuseppe Citerio

Authors
  1. Carolina B. Maciel
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  2. Brooke Barlow
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  9. Katie Dickinson
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  11. Guogen Shan
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Contributions

C.B.M. and K.M.B. conceptualized and designed the study; participated in acquisition, analysis, and interpretation of the data; drafted the initial manuscript; and revised it subsequently. B.B., M.M.P., B.L.-W., A.G., N.A.M., and Z.A.-M. participated in study conceptualization and design and data interpretation and visualization and revised the manuscript for intellectual content. G.M. and G.S. conducted the main data analysis and participated in interpretation of data as well as critical revision of the manuscript. R.A., F.B., L.H.M., K.D., and G.C. contributed to data acquisition, interpretation of the data, and critical revision of the manuscript for intellectual content. All authors reviewed and approved the final version of the manuscript.

Corresponding author

Correspondence to Katharina M. Busl.

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Conflict of interest

CBM has received honoraria from the American Academy of Neurology for speaking and writing. BB, BL-W, AG, ZA-M, MMP, RA, GM, GS, FB, KD, and NAM declare that they have no competing interests. LHM has received consulting fees from Novartis and Gryphon. GC reports grants and personal fees as a speakers’ bureau member and advisory board member from Integra and Neuroptics. KMB reports consulting fees from Techspert and Guidepoint Global and honoraria from the American Academy of Neurology for speaking, editing, and course directorship.

Ethical approval

The authors confirm adherence to ethical guidelines. Institutional review board approval was obtained through the University of Florida (IRB202100254), and individual consent was obtained as part of the survey by all participants.

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Maciel, C.B., Barlow, B., Lucke-Wold, B. et al. Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers. Neurocrit Care 38, 395–406 (2023). https://doi.org/10.1007/s12028-022-01571-7

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  • DOI: https://doi.org/10.1007/s12028-022-01571-7

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