Headache Management in Brain Bleed
Acetaminophen (paracetamol) is the only recommended analgesic for headache in patients with intracranial hemorrhage, while NSAIDs and aspirin-containing products are contraindicated due to increased bleeding risk. 1, 2
Recommended Medication
Acetaminophen should be administered at 1000 mg every 4-6 hours as needed, with a maximum daily dose of 4 grams. 2 This is the safest option because it lacks antiplatelet effects that could worsen bleeding. 2
Adjunctive Therapy
- Consider adding metoclopramide 10 mg if nausea is present, which provides synergistic analgesia and addresses associated symptoms common with intracranial hemorrhage. 2
Strictly Contraindicated Medications
The following medications are absolutely contraindicated in patients with brain bleeds:
All NSAIDs (ibuprofen, naproxen, diclofenac, meloxicam, ketorolac) are associated with increased bleeding risk and should be avoided. 1, 2 The 2022 AHA/ASA guidelines specifically classify regular long-term NSAID use as potentially harmful (Class 3: Harm recommendation). 1
Aspirin-containing combination products (such as aspirin-acetaminophen-caffeine combinations) are contraindicated. 2 Even low-dose aspirin increases intracranial hemorrhage risk. 3
Ketorolac is specifically contraindicated in patients with cerebrovascular hemorrhage. 2
Evidence Supporting NSAID Avoidance
Large meta-analyses demonstrate that NSAIDs, particularly diclofenac and meloxicam, increase hemorrhagic stroke risk. 1 Any NSAID use is associated with increased intracranial hemorrhage risk. 1
Critical Safety Considerations
Limit acute headache treatment to no more than 2 days per week to prevent medication-overuse headache. 2
Avoid opioids unless absolutely necessary, as they can mask neurological deterioration and lead to dependency. 2 This is particularly dangerous in brain bleed patients who require close neurological monitoring.
When to Escalate Care Immediately
Refer to neurology or neurosurgery urgently if:
- Headache is accompanied by new neurological deficits 2
- Altered mental status develops 2
- Worsening neurological examination 2
- "Thunderclap" sudden-onset severe headache develops, suggesting rebleeding 2
Common Clinical Pitfalls to Avoid
Do not restart antiplatelet therapy (if the patient was previously taking it) until the hemorrhage has stabilized and neurosurgical clearance is obtained, typically 2-14 days post-event. 2
Do not use aspirin for headache management even though it may have been the patient's prior medication for cardiovascular prophylaxis—the bleeding risk outweighs benefits in the acute setting. 2
Avoid combination analgesics that may contain hidden aspirin or NSAIDs without carefully checking ingredients. 2