What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?

In the immediate aftermath of a subarachnoid hemorrhage, regardless of whether the aneurysm has been secured or not, the following strategies can be employed to manage headaches:

• Headache Cocktail: This may consist of magnesium infusions, Benadryl, and an antiemetic like Compazine. Magnesium infusions are often effective.
• Valproic Acid: Administered as a rescue medication, 500 mg IV can be pushed over 15 minutes.
• Gabapentin: Rapid uptitration can be initiated, starting at 300mg TID and increasi...

I have encountered several male patients with non-aneurysmal SAH who experienced persistent and significant headaches. These patients, aged between 35 and 45, were all smokers, and I strongly suspected that two of them had OSA. The headaches sounded migrainous and none of the patients endorsed having headaches ahead of the SAH.

I followed three strategies:

Lifestyle changes were difficult with this population (regular meals, little protein at every meal, regular sleep, exercise, mindfulness, mag...

Check for vasospasm and hydrocephalus in either case.

In the hyper-acute phase (before securing the aneurysm), I typically administer IV Fentanyl to help patient feel at ease. However it's crucial not to overuse it, as this can lead to lethargy and potentially compromise the accuracy of the neuro-exam. Once aneurysm is secured, I initiate Gabapentin as a standing medication in addition to PRNs. Regarding PRNs, I've had positive results alternating between Fioricet & Tramadol as first/second-line agents. If Fioricet isn't overused or given for an ex...