The initial time-course of headache in patients with spontaneous subarachnoid hemorrhage

Background: If acute severe headache disappears early after its onset, the question arises whether subarachnoid hemorrhage (SAH) should still be ruled out. We studied the initial time-course and minimal duration of headache in a consecutive series of neurologically intact patients with spontaneous SAH. Methods: We included patients admitted between 2012 and 2015 within 48 h after spontaneous SAH with a normal level of consciousness and no focal deficits. We retrieved data on headache severity, measured with a Numeric Rating Scale (NRS), <48 h after ictus. We analyzed the proportion of patients with a first NRS 0 and NRS <3 within 48 h after ictus and minimal headache duration. Patients were censored in case of a decrease in level of consciousness, aneurysm treatment, or early discharge. Results: We included 106 patients (62 aneurysmal SAH, 33 perimesencephalic hemorrhage, 11 other spontaneous SAH). All patients were treated with analgesics. Within 48 h after ictus, a first NRS 0 was reported by 9 patients (8%:95%Cl:3%-14%) and a first NRS <3 by 22 patients (21%;95%CI:13%-28%). Shortest time lapse until NRS 0 was 10 h in a patient with aneurysmal SAH who had been on acetaminophen and tramadol since 2:35 h after ictus. Conclusions: In a cohort of SAH patients with a normal level of consciousness and no focal deficits who all used analgetics, headache disappeared in around 10% within 48 h after ictus. Our data indicate that a diagnostic work-up for SAH is also needed in patients using analgesics in whom headache has disappeared after 10 h. (C) 2017 Elsevier B.V. All rights reserved.