Headache Management in Mild Intracranial Hemorrhage
Acetaminophen (paracetamol) is the safest first-line analgesic for headache in patients with mild intracranial hemorrhage, while NSAIDs and all antiplatelet agents must be strictly avoided due to risk of hemorrhage expansion. 1, 2
Recommended Analgesic Approach
First-Line Treatment
- Acetaminophen 500-1000 mg every 6 hours is the preferred analgesic for headache control in the setting of intracranial hemorrhage 1, 2
- Acetaminophen provides moderate pain relief without affecting platelet function or increasing bleeding risk 3
- This recommendation applies regardless of cardiovascular history or concurrent beta blocker use 1
Medications to Strictly Avoid
- NSAIDs (ibuprofen, naproxen, ketorolac, indomethacin) are absolutely contraindicated in acute intracranial hemorrhage due to antiplatelet effects and risk of hemorrhage expansion 1
- Aspirin must be discontinued immediately if previously used, as it irreversibly inhibits platelet function 1
- Opioids should not be used for routine headache management due to dependency risk, rebound headaches, and medication overuse potential 1, 2
Critical Monitoring Requirements
Hemorrhage Expansion Risk
- Most hemorrhage expansion occurs within the first 6 hours after onset, making this the highest-risk period for any intervention that could worsen bleeding 4, 5
- Patients require continuous neurological assessments using validated scales (such as Glasgow Coma Scale) hourly for the first 24 hours 4
- Blood pressure must be monitored every 15-30 minutes during the acute phase, targeting systolic BP <140 mmHg within 6 hours 4
Follow-Up Imaging Protocol
- Repeat head CT at 6 and 24 hours after hemorrhage onset is recommended to exclude hemorrhage expansion, regardless of clinical stability 5
- Immediate repeat CT is mandatory for any neurological deterioration whatsoever 5
- Patients on anticoagulation (though metoprolol is not an anticoagulant) have 3-fold higher risk of hemorrhage progression and require closer monitoring 5
Special Considerations for This Patient
Beta Blocker Continuation
- Metoprolol should be continued as it does not increase bleeding risk and is important for cardiovascular disease management 1
- Beta blockers may actually help with blood pressure control during the acute hemorrhage period 4
Pain Relief Adequacy
- If acetaminophen provides insufficient pain relief, short-term opioid use (e.g., oxycodone 5 mg every 6 hours as needed) may be required for the first few days, but should be limited to avoid dependency 1, 2
- Reassess pain control at 24-48 hours and taper opioids as soon as feasible 1
Common Pitfalls to Avoid
- Never prescribe NSAIDs "just for a few days" in the setting of intracranial hemorrhage—even single doses increase bleeding risk 1
- Do not assume headache improvement means hemorrhage stability—imaging confirmation is required 5
- Avoid medication overuse by limiting acute headache treatment to fewer than 10 days per month once past the acute hemorrhage phase 1, 6
- Do not use combination analgesics containing aspirin or NSAIDs (e.g., Excedrin, which contains aspirin) 1, 6