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ORIGINAL ARTICLE
Cefaleia Dialítica Associada à Cefaleia por Privação de
Cafeína em Pacientes Submetidos à Hemodiálise
Dialysis Headache Associated with Caffeine-Withdrawal
Headache in Patients Undergoing Hemodialysis
Edarlan Barbosa dos-Santos
1
Kattiucy Gabrielle da Silva Brito
1
Bernardo Afonso Ribeiro Pinto
2
Tatiane Fernandes da Fonseca Gaban
2
Antonio Marcos da Silva Catharino
1,3,4
1
Universidade Iguaçu, Programa de iniciação
cientíca - Nova Iguaçu - Rio de Janeiro -
Brasil
2
Hospital Geral de Nova Iguaçu, Nefrologia -
Nova Iguaçu - Rio de Janeiro - Brasil
3
Hospital Geral de Nova Iguaçu, Neurologia -
Nova Iguaçu - Rio de Janeiro - Brasil
4
Universidade Iguaçu, Semiologia Médica \
Neurologia - Nova Iguaçu - Rio de Janeiro -
Brasil
*Correspondence
Antonio Marcos da Silva Catharino
E-mail: neurocurso@globo.com
Received: November 20, 2019.
Accepted: December 19, 2019.
DOI: 10.5935/2178-7468.20190027
ABSTRACT
RESUMO
Descritores: Cefaleia; Diálise Renal; Transtornos da Cefaleia.
Headaches are particularly relevant as a complication of hemodialysis, given
that this condition increases the discomfort felt by patients undergoing this
therapy. The objective of the present study was to evaluate the prevalence
of headache in patients undergoing hemodialysis sessions, particularly
considering dialysis headaches due to caffeine-withdrawal. This was a cross-
sectional, observational, quantitative and qualitative study with questionnaires
and interviews. The questionnaire addressed biopsychosocial aspects, clinical
aspects and criteria for the classication of headaches according to the
International Headache Society. A hundred and sixty patients with stage-V
chronic kidney disease responded to the questionnaire during hemodialysis
sessions. Headache prevalence was 90% and over the period studied 53.1% of
patients presented the symptom. Among these patients with headaches, over
half (55.3%) presented criteria for concomitant caffeine-withdrawal headaches
and dialysis headaches. The beginning of headaches varied between one
month and more than ve years, with most occurring for more than ve years.
Frequency varied from sporadic crises to more than one crisis a day, though
more than one crisis a day predominated. The interval between crises was of
a few days, with mean duration of less than one hour, which ceased with the
use of self-medicated analgesics, with no worsening factor. This condition is
a challenge for neurologists and headache experts. More studies are needed
to decrease this prevalence, to decrease the abusive use of analgesics and
improve the quality of life of these patients.
Keywords: Headache; Renal Dialysis; Headache Disorders.
A cefaleia como complicação da hemodiálise merece um lugar de destaque,
uma vez que aumenta ainda mais o incômodo sofrido pelo paciente submetido
a essa terapia. O objetivo deste trabalho é estudar a prevalência de cefaleia
em pacientes submetidos a sessões de hemodiálise, com ênfase na cefaleia
dialítica e na cefaleia por privação de cafeína. Este foi um estudo transversal,
observacional, quantitativo e qualitativo utilizando questionários e entrevistas.
O questionário abordou aspectos biopsicossociais, aspectos clínicos e critérios
para classicação da cefaleia de acordo com a Sociedade Internacional de
Cefaleia. Cento e sessenta pacientes com IRC em estágio V responderam ao
questionário durante as sessões de hemodiálise. A prevalência da cefaleia foi
de 90% e no período da pesquisa 53,1% dos pacientes apresentavam o sintoma.
Dentre os pacientes com cefaleia, mais da metade (55,3%) apresentavam critérios
para cefaleia por privação de cafeína e cefaleia dialítica concomitantemente. O
início da cefaleia variou de um mês a mais de cinco anos, sendo a maioria há
mais de cinco anos. A frequência variou de crises esporádicas a mais de uma
crise por dia, predominando mais de uma crise por semana. O intervalo entre
as crises foi de dias, com duração média de menos de uma hora, sendo cessada
com uso de analgésicos, automedicados, sem fator agravante. Essa condição é
considerada um desao entre os neurologistas e especialistas em cefaleia. São
necessários mais estudos para diminuir essa prevalência, diminuir o uso abusivo
de analgésicos e melhorar a qualidade de vida desses pacientes.
Dialysis Headache Associated with Caffeine-Withdrawal
Santos EB, et al.
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INTRODUCTION
Headaches are classied as either primary or
secondary, based on the absence or not of underlying
structural or metabolic disruptions causing the condition.
This is a very frequent symptom in patients with renal
failure undergoing hemodialysis.
1
Headaches are triggered by several factors, which
are either intrinsic or extrinsic, since individuals with
migraines have lower thresholds to certain exposures,
leading to a series of events and culminating in pain.
2
Headaches are particularly relevant as a
complication of hemodialysis, given that this condition
increases the discomfort felt by patients undergoing
this therapy. Moreover, there is an increasing number
of patients that rely on this procedure. The relationship
between hemodialysis and headaches can be observed
at the beginning of the dialysis treatment, which can
be followed by nausea, vomiting, muscle spasms,
disorientation, systemic hypertension and convulsions.
3,4
The most frequent triggering factors for dialysis
headache, either mentioned by patients or by the medical
team, were arterial hypertension (38%), followed by no
identied factor (26%), arterial hypotension (12%) and
changes to body weight (6%). Another factor mentioned
as a trigger for headaches during hemodialysis were
electrolyte disorders.
5
Dialysis headache frequency was rst described in
1972, with 70% of hemodialysis patients suffering from
headaches. Over the years, this frequency decreased, as
shown in a recent study where this proportion was of 48%.
6
During hemodialysis, several substances are
depurated. The International Headache Society (IHS)
emphasizes the decrease of serum caffeine as being
responsible for headache crises during dialysis sessions.
The main symptom of cessation of caffeine is headache.
7
The study of Maia and cols. reports the benets of using
caffeine before hemodialysis sessions as a prophylactic
measure for headaches.
8
The objective of the present study was to evaluate
the prevalence of headache in patients undergoing
hemodialysis sessions, particularly considering dialysis
headaches due to caffeine-withdrawal.
MATERIAL AND METHODS
This was a cross-sectional, observational, quantitative
and qualitative study conducted at a treatment center
for patients with renal failure who were undergoing
hemodialysis. The study comprised questionnaires and
interviews with these patients.
The questionnaire was developed by the authors
and addressed biopsychosocial aspects (age, gender,
housing, life habits, previous pathological history,
professional activities, among others), in addition to
clinical aspects regarding the presence of headaches
(family history, time of disease, frequency, duration,
location, intensity, quality of pain, associated symptoms,
triggering factors, worsening factors and relief factors
during a crisis) and criteria for the classication of
headaches according to the IHS.
The Google Docs software was used to manage the
database of this research. All patients were consulted in
advance and manifested their interest in taking part of
this investigation by signing a free and informed consent
statement. Thus, patients answered the questionnaire
voluntarily after agreeing to participate in the research.
This project was approved by the ethics in research
committee of the educational institution - UNIG, CAAE:
68978517.4.0000.8044, registry number: 2.416.322.
RESULTS
Questionnaires were applied to 160 patients, with
stage-V chronic kidney disease, during hemodialysis
sessions. Most patients were in their 70s (25%), followed
by patients in their 50s (21.2%). Moreover, most patients
were male (61.9%). Regarding marital status, most
patients were married, and more than half lived with
their spouse and/or children. Over 60% considered
themselves stressed and mentioned hemodialysis and
one of the causes. Only 9% were smokers and 10%
reported drinking alcoholic beverages for more than 10
years. Only 18% carried out physical or cultural activities
regularly. All patients reported not having a professional
occupation because of the disease and 70% reported
feeling difculty in their everyday life. Nearly 87% of
patients presented associated arterial hypertension.
Headache prevalence was 90% and over the period
studied 53.1% of patients presented the symptom. Among
these patients with headaches, over half (55.3%) presented
criteria for concomitant caffeine-withdrawal headaches
and dialysis headaches. In turn, 14.1% only presented criteria
for dialysis headaches, according to the IHS.
The beginning of headaches varied between one
month and more than ve years, with most occurring for
more than ve years. Frequency varied from sporadic
crises to more than one crisis a day, though more than
one crisis a day predominated, which was compatible
with hemodialysis sessions three times a week. The
interval between crises was of a few days, with mean
duration of less than one hour, which ceased with the use
of self-medicated analgesics, with no worsening factor.
The prevailing location of the pain was the front bilateral
region, followed by the occipital and temporal regions,
characterized as pulsating, with no aura, frequently
associated with other symptoms such as scintillating
scotomas, nausea, vomiting and photophobia. When
asked about colors, most patients associated intensity of
pain with the color red, followed by black.
CONCLUSION AND DISCUSSION
A high prevalence of dialysis headache was
observed, a frequent complication of hemodialysis
that worsens the quality of life of patients that already
present a debilitating disease. This condition is a
challenge for neurologists and headache experts. The
association between dialysis headache and headache
by caffeine-withdrawal was observed in more than half
of the patients with any kind of headache. More studies
are needed to decrease this prevalence, to decrease the
Dialysis Headache Associated with Caffeine-Withdrawal
Santos EB, et al.
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abusive use of analgesics and improve the quality of life
of these patients.
All patients reported that their headaches only
improved with the use of analgesics. However, there
are no controlled studies on prophylactic treatment or
abortive treatment of dialysis headache.
9
Frontal bilateral pain, characterized as pulsatile, with
no aura, frequently associated with other symptoms
such as scintillating scotomas, nausea, vomiting and
photophobia is compatible with the literature found.
Despite their high prevalence, dialysis headaches
remain scarcely studied.
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