What medication should be given for a severe headache due to Subarachnoid Hemorrhage (SAH)?

Medication Management for Severe Headache in Subarachnoid Hemorrhage

For confirmed SAH, immediately initiate oral nimodipine 60 mg every 4 hours for 21 consecutive days, starting within 96 hours of hemorrhage onset—this is the only medication proven to reduce cerebral infarction and improve neurological outcomes. 1, 2, 3

Primary Treatment: Nimodipine

Nimodipine is a Class I, Level of Evidence A recommendation from the American Heart Association and represents the cornerstone of medical management for SAH-related complications. 1

Dosing and Administration

• Standard dose: 60 mg (two 30 mg capsules) orally every 4 hours for 21 consecutive days 3
• Timing: Must be initiated within 96 hours of hemorrhage onset 2, 3
• Administration route: Oral capsules should be swallowed whole, preferably 1 hour before or 2 hours after meals 3
• Alternative administration: If the patient cannot swallow (unconscious, post-surgical), extract capsule contents with an 18-gauge needle into a syringe labeled "Not for IV Use" and administer via nasogastric tube followed by 30 mL normal saline flush 3

Critical Safety Warning

Never administer nimodipine intravenously—this can cause life-threatening hypotension requiring cardiovascular support with pressors. 3

Mechanism and Efficacy

• Nimodipine reduces cerebral infarction by 34% and poor outcomes by 40% 1
• It provides a 24% relative risk reduction in poor outcome (death or dependency) 4
• The number needed to treat is 13 patients to prevent one poor outcome 4
• Importantly, nimodipine does not prevent angiographic vasospasm but improves outcomes through neuroprotective mechanisms including cerebral vasodilation of small pial vessels and reduction of intracellular calcium-mediated ischemic injury 1, 5, 4

Dose Modifications

In patients with severe liver dysfunction (cirrhosis), reduce dose to 30 mg every 4 hours with close blood pressure and heart rate monitoring, as bioavailability doubles in hepatic impairment. 3

• Only 43.6% of eligible patients receive the full dose in clinical practice 6
• Dose reduction by 50% is required in 28.6% of patients due to hypotension or high catecholamine requirements 6
• Application of full nimodipine dosage is associated with reduced risk of unfavorable outcome (OR 0.895, p=0.029), so maintain full dosing whenever hemodynamically tolerable 6

Drug Interactions

• Avoid grapefruit juice (increases bioavailability) 3
• Do not co-administer with strong CYP3A4 inhibitors (contraindicated) 3
• Avoid strong CYP3A4 inducers (may reduce efficacy) 3
• Patients on moderate CYP3A4 inhibitors may require dose reduction if hypotension develops 3

Medications to Avoid

Do not use routine statin therapy or intravenous magnesium sulfate for vasospasm prophylaxis—these have been proven ineffective in improving outcomes. 7, 1

• Statins reduce vasospasm but show no benefit in delayed cerebral ischemia or mortality 7
• Magnesium sulfate shows no benefit in cerebral infarction or mortality reduction 7
• Aspirin, enoxaparin, and tirilazad are ineffective 1

Symptomatic Headache Management

For severe headache symptoms in SAH patients (once diagnosis is confirmed), avoid opioids due to risk of dependence and rebound headache; focus on definitive aneurysm treatment and nimodipine rather than analgesics. 2

The evidence does not support specific analgesic regimens for SAH-related headache beyond nimodipine, as the priority shifts immediately to preventing rebleeding and delayed cerebral ischemia rather than symptomatic pain control.

Blood Pressure Management

Control blood pressure with titratable agents between symptom onset and aneurysm obliteration, balancing rebleeding risk against maintaining cerebral perfusion pressure. 1, 8

• Maintain euvolemia and normal circulating blood volume 1, 8
• Avoid prophylactic hypervolemia and triple-H therapy (hypervolemia, hypertension, hemodilution)—these increase complications without improving outcomes 1, 8, 5
• For symptomatic delayed cerebral ischemia, elevate blood pressure (induced hypertension) while maintaining euvolemia 1

Common Pitfalls

• Hypotension from nimodipine: This occurs frequently and may necessitate dose reduction, but attempt to maintain full dosing as it correlates with better outcomes 6
• Delayed initiation: Nimodipine must start within 96 hours; later initiation loses efficacy 2, 3
• IV administration error: This is a potentially fatal mistake that requires immediate recognition and cardiovascular support 3
• Premature discontinuation: The full 21-day course is necessary even if the patient appears to improve 3