From the Guidelines
Patients with VP shunts who develop new or worsening headaches should seek immediate medical attention to rule out shunt malfunction, which can lead to increased intracranial pressure and potentially life-threatening complications. Headaches in patients with VP shunts can be caused by various factors, including shunt malfunction, overdrainage, or underlying conditions such as idiopathic intracranial hypertension (IIH) 1.
Initial Evaluation
When evaluating a patient with a VP shunt and headache, it is essential to consider the underlying cause of the headache and to assess for signs of shunt malfunction, such as worsening headache when lying down or in the morning, nausea, vomiting, visual changes, altered mental status, or fever. Initial management includes neuroimaging (CT or MRI) to assess ventricular size and shunt placement, along with a shunt series (X-rays) to check for disconnections or kinks 1.
Management
While awaiting neurosurgical evaluation, acetaminophen (500-1000mg every 6 hours) can be used for pain management, but NSAIDs should be avoided due to bleeding risk 1. Patients should be positioned with the head elevated to reduce intracranial pressure. Shunt revision should not routinely be undertaken unless there is papilloedema and a risk of visual deterioration 1. Many patients with IIH may be in ocular remission, and conservative management with migraine therapies and treatment of medication overuse should be tried initially 1.
Follow-up
Regular follow-ups with neurosurgery are essential for patients with VP shunts to monitor for complications and to adjust the shunt as needed. Adjustable valves with antigravity or antisiphon devices should be considered for use to reduce the risk of low pressure headaches 1. Patients should also be counselled on the importance of informing the Driver and Vehicle Licensing Agency following VP shunt placement, as recommended by best practice guidelines 1.
From the Research
VP Shunt and Headache
- The relationship between VP shunts and headaches is complex, with various studies attempting to understand the underlying pathophysiology and treatment options 2, 3.
- A study published in 2008 identified five different pathophysiologies involved in shunt-related headaches, including severe intracranial hypotension, intermittent obstruction of the ventricular catheter, intracranial hypertension with small ventricles and a failed shunt, intracranial hypertension with a working shunt, and shunt-related migraine 2.
- The treatment of these conditions and identifying patients with each condition are facilitated by attempting to remove the shunt, with about a quarter of patients able to have the shunt removed without replacement 2.
- Another study published in 2009 found that headaches are a common affliction in patients with shunts, with severe headaches becoming a more frequent problem as the age of the population treated for hydrocephalus increases 3.
- The incidence of headaches in patients with shunts is likely higher than in normal populations, with early treatment decisions having a significant effect on later quality of life 3.
Shunt Malfunction and Revision
- Ventriculoperitoneal shunts are known to have high malfunction rates, with mechanical causes being the most common reason for malfunction 4, 5.
- A study published in 2018 found that the overall shunt revision rate was 51.9%, with the shunt revision rate within the first 6 months after the initial placement of ventriculoperitoneal shunts being 45.1% 5.
- Major causes of shunt revision include infection, overdrainage, obstruction, proximal shunt complication, distal shunt complication, old shunt dysfunction, valve malfunction, externalization, shunt complication, shunt adjustment/replacement, and other complications 5.
Nursing Care and Patient Management
- Nurses play a crucial role in caring for patients who have undergone shunt placement or revision, with a thorough understanding of the indications for VP shunt placement, possible complications, and nursing care for patients following a shunt placement procedure being essential 6.
- The management of headaches in patients with shunts requires a comprehensive approach, with strategies that lead to normalization of cerebrospinal fluid dynamics and life without shunt dependency being justified if they can be shown to improve later quality of life 3.