Severe headache trajectory following aneurysmal subarachnoid hemorrhage: the association with lower sodium levels

Abstract

Background: A clinical hallmark of aneurysmal SAH (aSAH) is headache. Little is known about post-aSAH headache factors which may point to underlying mechanisms. In this study, we aimed to characterize the severity and trajectory of headaches in relation to clinical features of patients with aSAH.

Methods: This is a retrospective longitudinal study of adult patients admitted to an academic tertiary care center between 2012 and 2019 with aSAH who could verbalize pain scores. Factors recorded included demographics, aneurysm characteristics, analgesia, daily morning serum sodium concentration, and occurrence of vasospasm. Group-based trajectory modeling was used to identify headache pain trajectories, and clinical factors were compared between trajectories.

Results: Of 91 patients included in the analysis, mean age was 57 years and 20 (22%) were male. Headache score trajectories clustered into two groups: patients with mild-moderate and moderate-severe pain. Patients in the moderate-severe pain group were younger (P<0.05), received more opioid analgesia (P<0.001), and had lower sodium concentrations (P<0.001) than patients in the mild-moderate pain group.

Conclusion: We identified two distinct post-aSAH headache pain trajectory cohorts and identified an association with age, analgesia, and sodium levels. Future prospective studies considering sodium homeostasis and volume status under standardized analgesic regimens are warranted.

Keywords: Aneurysmal subarachnoid hemorrhage; SIADH; headache; hyponatremia; opioids; sodium; vasospasm.

Figure 1.

HA = headache; PBD = post bleed day; OME = oral morphine equivalents. (a) Average maximum daily headache scores across participants with plus and minus two standard errors. Light gray lines indicate the raw data. (b-c) The two trajectory groups, mild-moderate and moderate-severe, and their corresponding average headache trajectory as well as raw subject-level data. (d-g) Comparison of age, OME, fioricet tabs, and sodium in patients assigned to the mild-moderate versus the moderate-severe headache groups.