From the Guidelines
To reduce intradialytic headaches, it is crucial to implement strategies that minimize hypotensive symptoms and maintain stable blood pressure during dialysis, such as avoiding excessive ultrafiltration, adjusting dialysate sodium concentration, and reducing dialysate temperature. Several approaches can be taken to achieve this, including:
- Avoiding excessive ultrafiltration rates and large interdialytic weight gains, aiming for less than 2-3% of dry weight removal per session 1
- Adjusting dialysate sodium concentration to match the patient's serum sodium, typically starting at 138-140 mEq/L, to prevent rapid osmotic shifts 1
- Maintaining stable blood pressure during dialysis by using a lower dialysate temperature, such as 35-36°C instead of 37°C, which can increase peripheral vasoconstriction and cardiac output 1
- Considering midodrine 5-10 mg before dialysis for patients with hypotension to help maintain blood pressure stability 1
- Ensuring adequate dialysis clearance by optimizing treatment time and blood flow rates to prevent rapid fluid shifts and maintain cerebral perfusion
- Using bicarbonate-containing dialysate instead of acetate-containing dialysate, as it can minimize hypotension, cramps, and headaches, and reduce nausea and vomiting 1 These strategies can help prevent rapid fluid shifts, maintain cerebral perfusion, and address the physiological triggers of headaches during dialysis, ultimately reducing the incidence of intradialytic headaches and improving patient outcomes.
From the Research
Intradialytic Headaches
- Intradialytic headaches are a common complication of hemodialysis, affecting a significant proportion of patients 2, 3.
- The exact pathophysiology of intradialytic headaches is not fully understood, but it is thought to be related to changes in blood pressure, electrolyte shifts, and urea reduction during dialysis 2, 3.
- Studies have shown that patients with intradialytic headaches tend to have higher pre-dialysis blood pressure values and greater changes in blood pressure during dialysis 2, 3.
Prevention and Management
- Regulating the frequency and timing of dialysis may help reduce the incidence of intradialytic headaches, particularly in patients with high blood urea nitrogen (BUN) levels and high pre-dialysis blood pressure 3.
- Optimizing the dialysis prescription and interventions during and after the dialysis session may also be effective in reducing the risk of intradialytic hypotension, which is often associated with headaches 4.
- Withholding blood pressure medications before hemodialysis is not recommended as a routine practice, as it may not prevent intradialytic hypotension and could potentially worsen outcomes 5.
Clinical Characteristics
- Intradialytic headaches are often characterized by a fronto-temporal location, moderate severity, throbbing quality, and short duration (<4 hours) 2, 3.
- The headaches typically start 2-3 hours after the initiation of dialysis and resolve within a few hours after the completion of the dialysis session 3.
- The frequency and severity of intradialytic headaches can vary widely between patients, and individualized approaches to prevention and management may be necessary 2, 3.