What medications are used to treat post shunt headache?

Medications for Post Shunt Headache

NSAIDs and acetaminophen should be used as first-line treatment for post shunt headaches, with ibuprofen 400-800 mg or naproxen sodium 275-550 mg being the preferred options. 1 Post shunt headaches can have various underlying causes, and treatment should be tailored to the specific pathophysiology while following a stepped care approach.

Understanding Post Shunt Headache Pathophysiology

Post shunt headaches can occur due to several mechanisms:

1. Intracranial hypotension - Similar to spinal headaches, caused by excessive CSF drainage 2
2. Intermittent obstruction of the ventricular catheter 2
3. Intracranial hypertension with small ventricles (failed shunt) 2
4. Intracranial hypertension with working shunt 2
5. Shunt-related migraine - Migrainous features triggered by shunt 2

Treatment Algorithm

First-Line Therapy

• NSAIDs (oral) 1

  • Ibuprofen 400-800 mg every 6 hours (maximum 2.4g/day) 1
  • Naproxen sodium 275-550 mg every 2-6 hours (maximum 1.5g/day) 1
  • Aspirin 650-1000 mg every 4-6 hours (maximum 4g/day) 1

• Acetaminophen combinations 1

  • Acetaminophen 1000 mg (note: acetaminophen alone is less effective than NSAIDs) 1, 3
  • Acetaminophen-aspirin-caffeine combination 1

Second-Line Therapy (for moderate-severe headaches or those not responding to NSAIDs)

• Triptans 1
  • Sumatriptan 50-100 mg orally (most effective when taken early) 1
  • Rizatriptan 5-20 mg orally 1
  • Zolmitriptan 2.5-5 mg orally 1

Third-Line Therapy

• For migrainous features resistant to above treatments:
  • Lasmiditan (ditan) - though benefits must be weighed against driving impairment 1
  • Gepants (ubrogepant, rimegepant) 1

Adjunctive Therapy

• For nausea/vomiting:

  • Metoclopramide 10 mg (also improves gastric motility) 1
  • Prochlorperazine 25 mg (can also help with headache pain) 1

• For postural headache (suggesting intracranial hypotension):

  • Consider epidural blood patch if symptoms suggest low-pressure headache 4

Special Considerations

1. Avoid opioids and butalbital-containing analgesics except as last resort due to risk of dependence and medication overuse headache 1

2. For patients with shunt-related intracranial hypertension:

   • Acetazolamide may be considered (starting at 250-500 mg twice daily) 1

3. For frequent or chronic post-shunt headaches:

   • Consider migraine preventive medications if headaches have migrainous features 1
   • Evaluate for possible shunt malfunction or need for shunt revision 2

4. Medication overuse risk:

   • Limit acute medications to 2 days per week or maximum 10 days per month 1
   • Monitor for development of medication overuse headache 1

Important Caveats

• Post-shunt headaches are more common than in the general population and can significantly impact quality of life 5, 6
• Headache in shunted patients should trigger evaluation for shunt malfunction before assuming it's a primary headache disorder 2
• Patients with shunts who develop new or changed headache patterns should be evaluated for possible shunt complications 2
• Postural headaches (worse when upright, better when lying down) may suggest overdrainage and intracranial hypotension 1, 4

By following this stepped care approach and considering the underlying pathophysiology, most post-shunt headaches can be effectively managed with appropriate medication selection.