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ABSTRACT
RESUMO
Descritores: Cefaleias secundárias; Procedimentos diagnósticos; Procedimentos
terapêuticos
VIEWS AND REVIEWS
Clinical characteristics of headaches attributed to
diagnostic and therapeutic procedures
Características clínicas das cefaleias atribuídas a
procedimentos diagnósticos e terapëuticos
Raimundo Pereira Silva-Néto
1
1
Federal University of the Parnaíba Delta,
Brazil.
*Correspondence
Raimundo Pereira Silva-Néto
Universidade Federal do Delta do
Parnaíba, Avenida São Sebastião, 2819,
Fátima, Parnaíba, PI
64001-020, Brasil. Tel. + 55 3237-2104.
E-mail: neurocefaleia@terra.com.br
Received: December 5, 2019.
Accepted: December 12, 2019.
Headaches may appear after performing diagnostic and / or therapeutic
procedures with close temporal relationship to these events. The objective of
this research was to know the clinical characteristics of headache secondary to
diagnostic and / or therapeutic procedures. We reviewed secondary headaches
according to ICHD-3, and searched for those that arose after performing a
diagnostic and / or therapeutic procedure. A total of 11 different diagnoses
of headache attributed to diagnostic and / or therapeutic procedures were
found. Some secondary headaches are due to diagnostic and / or therapeutic
procedures.
Keywords: Secondary headaches; Diagnostic procedures; Therapeutic
procedures.
Cefaleias podem surgir após realização de procedimentos diagnósticos e/ou
terapêuticos com estreita relação temporal com esses eventos. O objetivo
desta pesquisa foi conhecer as características clínicas das cefaleias secundárias
a procedimentos diagnósticos e/ou terapêuticos. Nós revisamos as cefaleias
secundárias, de acordo com a ICHD-3, e buscamos aquelas que surgiram
após a realização de um procedimento diagnóstico e / ou terapêutico. Foram
encontrados 11 diagnósticos diferentes de cefaleias atribuídas a procedimentos
diagnósticos e / ou terapêuticos. Algumas cefaleias secundárias são decorrentes
de procedimentos diagnósticos e/ou terapêuticos.
INTRODUCTION
Secondary headache is dened
when a new headache occurs for
the rst time in close temporal
relationship to an intracranial
disorder
1
. The clinical presentation
of all these disorders can be diverse
and often mimics the characteristics
of primary headaches, which may
delay the diagnosis
2
.
Headache may appear as a side
effect due to the performance of
some diagnostic and / or therapeutic
procedures, such as neurosurgery,
endovascular treatments, puncture
of the dura mater for cerebrospinal
uid (CSF) removal or injection of
some substance, among others
1
.
Knowledge of the clinical char-
acteristics of these headaches is
important to improve diagnostic
accuracy and therapeutic manage-
ment, as well as the development of
prophylactic measures.
METHODS
In this review, we examined the
diagnosis of all secondary head-
aches, according to International
Classication of Headache Disor-
ders, Third Edition (ICHD-3)
1
. The
headaches that appeared after per-
forming a diagnostic and / or thera-
peutic procedure were selected. In
addition, we seek articles related to
these headaches in the main data-
bases to better characterize them.
RESULTS
A total of 11 different diagnoses
of headache attributed to diagnostic
and / or therapeutic procedures
were found (Table 1).
Clinical characteristics of headaches
Silva-Néto RP.
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DISCUSSION
According to ICHD-3
1
, some diagnostic and /
or therapeutic procedures may cause headache. In
the following, these headaches that are considered
secondary will be described.
Acute or persistent headache attributed to
craniotomy
A craniotomy is a neurosurgical technique, whereby
part of the skull is opened or removed for access to
treat conditions such as brain tumors, aneurysms, and
arteriovenous malformations
3
.
Retrospective studies have shown that more than
30% of the patients submitted to this surgical procedure
had headache attributed to craniotomy as an adverse
event
4-6
.
However, when headache occurs after head injury
surgery, it will be coded as acute headache attributed to
moderate or severe traumatic head injury.
According to ICHD-3, this headache must have
occurred within seven days after craniotomy, after
the patient has regained consciousness or after
discontinuation of medications that impair the ability to
feel or report headache. In addition, headache should be
resolved within three months of its initiation
1
.
Headache attributed to craniotomy is more common
after surgery of the skull base compared to other
locations. Usually, it is felt at the site of the craniotomy,
but may be more diffuse and resemble tension-type
headache or migraine
1
.
If headache resolved within three months after its
onset, it will be classied as acute, but if it persists for
more than three months, it will be called chronic. When
headache following craniotomy becomes persistent, the
possibility of medication-overuse headache needs to be
considered
1
.
In the abortive treatment of this headache, several
drugs have been tried, such as inltration of the scar
with local anesthesia
7
, opioids, especially codeine
and morphine, acetaminophen, non-hormonal anti-
inammatories
8
, and sumatriptan
9
. There are few studies
on prophylactic treatment of headache attributed to
craniotomy
10
. The best therapeutic responses were with
verapamil
11
and divalproex sodium
12
.
Post-endarterectomy headache
This headache is caused by the surgical procedure
of carotid endarterectomy. It develops within one week
after of the carotid endarterectomy, but it is resolved
within the rst 30 days. Headache can occur without any
other associated symptom or be a warning symptom
preceding the focal decits of (mostly hemorrhagic)
stroke
1
.
Headache is unilateral, on the side of carotid
endarterectomy, and may involve the neck and face. The
headache has a pulsating character and a mild intensity.
It manifests as cluster headache-like pain occurring once
or twice a day in attacks lasting two to three hours
1
.
There are three subforms of post-endarterectomy
headache, but they are not coded separately. The rst is
the most frequent (up to 60% of cases), a diffuse, mild
and isolated headache, which occurs in the rst days
after surgery and is a benign, self-limiting condition;
the second (up to 38% of cases), a unilateral cluster
headache-like pain with attacks, lasting two to three
hours, occurring once or twice a day and resolves in
about two weeks; and the third, unilateral pulsating and
severe pain occurring three days after surgery. This latter
subform is part of the rare hyperperfusion syndrome,
often preceding a rise in blood pressure and the onset of
seizures or neurological decits on or about the seventh
day. Urgent treatment is required, since these symptoms
can herald cerebral haemorrhage
1
.
Some studies have shown that headache occurs
in 38% to 62% of patients undergoing endarterectomy.
Usually, the location of the pain is on the same side of
the surgical procedure. It has a dull or pressure character
and a moderate to severe intensity. In more than 50%
of patients there is no need for treatment
13,14
, but when
it is part of the hyperfusion syndrome, treatment is an
emergency as these symptoms may indicate a brain
hemorrhage.
Headache attributed to carotid or vertebral
angioplasty or stenting
Carotid and vertebral angioplasty and/or stenting are
performed to treat patients with cervical artery stenosis,
but one-third of these patients develops headache. This
headache is caused by the endovascular procedures of
carotid or cervical angioplasty and / or stenting without
arterial dissection. It develops within a week but resolves
within a one month after angioplasty and / or stenting
1
.
Headache attacks usually occur within 10 minutes
in which these procedures are performed. They are
localized to the frontotemporal region, ipsilateral to
the procedure, in pressure, mild intensity, and lasting a
maximum of 10 minutes.
Studies show that carotid percutaneous transluminal
angioplasty may cause arterial dissection, often resulting
Acute or persistent headache attributed to craniotomy
Post-endarterectomy headache
Headache attributed to carotid or vertebral angioplasty or
stenting
Headache attributed to cranial venous sinus stenting
Headache attributed to an intracranial endarterial procedure
Angiography headache
Post-dural puncture headache
Headache attributed to intrathecal injection
Dialysis headache
Headache attributed to radiosurgery of the brain
Post-electroconvulsive therapy headache
Table 1. Headaches attributed to diagnostic and / or
therapeutic procedures, according to ICHD-3
Clinical characteristics of headaches
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in cervical, facial or cranial pain. However, the relative
risk of painful dilation depends on individual risk factors,
such as a history of myocardial infarction. In addition,
the radiation pattern of pain depends on which carotid
segment is dilated
15
.
Data on carotid angioplasty headache and
diagnostic criteria are based on few studies. Despite the
scarcity of data, this headache seems to be relatively
frequent. In two studies, its occurrence ranged from 39%
to 51%
15,16
.
Headache attributed to cranial venous sinus
stenting
In recent years, lateral sinus stenosis stenting has
been used in the treatment of idiopathic intracranial
hypertension. Suppression of stenosis may reduce
intracranial pressure by decreasing the pressure in the
upper longitudinal sinus. However, unilateral headache
may be caused by the stent and on the same side of the
cranial venous sinus stent
17
.
This headache devolops within one week after the
jugular or cranial venous stent has been performed.
Headache is ipsilateral to the stenting and it resolves
within three months
1
.
In one series of 21patients stented for idiopathic
intracranial hypertension, 10 patients exhibited ‘stent-
headaches’ differing from those experienced before
treatment, located at the site of the stent, in the mastoid
region, and lasting about three weeks. These “stent-
headaches” disappeared after 3 months of stenting
17
.
Headache attributed to an intracranial
endarterial procedure
Some studies have shown that balloon ination in the
intracranial arteries during therapeutic embolization of
intracerebral arteriovenous malformations (AVMs) cause
pain by distension of these vessels
18
. Probably, mechanical
vessel distension activates the trigeminovascular
nociceptive system in susceptible individuals
19
.
It is a unilateral headache directly caused by
intracranial endarterial procedure, ipsilateral to the
procedure and lasting less than 24 hours. Pain was
described as brief, sharp or localized pressure of mild to
moderate intensity, felt ipsilaterally to the manipulated
vessel. This headache develops within one week and
resolves within one month after the procedure
1,19
.
The occurrence of this headache during
endovascular procedures is not yet well-dened.
There is limited information to dene its frequency,
risk factors, pathogenesis and implications for future
pain management
19
. In some evaluated procedures,
the headache occurrence attributed to an intracranial
endoarterial procedure ranged from 10.6% to 68.0%
18-21
.
Angiography headache
This headache is caused by intra-arterial carotid
or vertebral angiography. It develops during contrast
injection or within 24 hours after angiography, lasting
less than one hour. It disappears within 72 hours after
angiography
1
.
The frequency of post angiography headache
ranges from 30.2% to 39.1%
16,22,23
. Possibly a headache
is due to irritation of the trigeminovascular system by
contrast agents or mechanical stimuli, resulting in the
release of vasoactive peptides
24
.
Post-dural puncture headache
Headache occurring within ve days of a lumbar
puncture, caused by CSF leakage through the dural
puncture. It is usually accompanied by neck stiffness
and / or subjective hearing symptoms and it gets worse
when the individual takes the upright position. It remits
spontaneously within two weeks, or after healing from
the leak with autologous epidural lumbar patch
1
.
Puncture of the dura-mater occurs during diagnostic
or therapeutic procedures, spinal anesthesia or
inadvertently during epidural anesthesia. After puncture,
post-dural puncture headache may appear as a common
complication in approximately 7.5% of the patients
25,26
.
Headache attributed to intrathecal injection
Some drugs that act on the central nervous system
such as analgesics, anesthetics, and antineoplastics
are injected directly into the subarachnoid space,
thus avoiding the blood-brain barrier. This route
of administration is known as the subarachnoid or
intrathecal route.
After intrathecal injection, the most common adverse
effects are headache and low back pain
27
. Headache
develops within four days of intrathecal injection and
signicantly improves within 14 days after intrathecal
injection. Signs of meningeal irritation are present. In
addition, headache experienced in both upright and
recumbent postures
1
.
Dialysis headache
Dialysis is a therapeutic procedure used by
patients with kidney failure, where a machine replaces
the diseased kidney and lters the blood, eliminating
toxic substances such as sodium, potassium, urea and
creatinine. Frequently, patients with chronic kidney
disease experience headache during dialysis
28
, whose
pathophysiology is still unknown.
The prevalence of dialysis headache varies between
27% and 73%
28
. This headache is characterized by
developing during a hemodialysis session and resolving
within 72 hours after the end of the dialysis session.
Headache episodes cease altogether after successful
kidney transplantation and termination of haemodialysis
1
.
Dialysis headache was described for the rst time
by Bana and Yap in 1972
29
, but its clinical characterization
has been detailed improvement in recent years. In
most patients, headache is pulsatile, located in the
frontal region, moderate to severe intensity, and may
be accompanied by nausea and vomiting
30-33
. There are
Clinical characteristics of headaches
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no controlled studies on the prophylactic or abortive
treatment of dialysis headache.
Headache attributed to radiosurgery of the
brain
Brain radiosurgery is used in the treatment of brain
injuries, such as arteriovenous malformations
34
and
intracranial tumors
35
. In some primary headaches, such
as refractory cluster headache, brain radiosurgery may
also be useful
36
. Cerebral edema is the most frequent
complication of this procedure
37,38
.
More rarely, headache may appear in a patient in
whom radiosurgery of the brain has been performed. It
develops within seven days, but it is resolved within three
months after radiosurgery. There have been no validation
studies of its diagnostic criteria. Currently, it is in the
appendix of ICHD-3 (A5.7), but it is not better accounted
for by another ICHD-3 diagnosis
1
.
Studies on this new headache do not provided
detailed descriptions of its clinical features. In some
cases, the headache syndrome was short-lived, occurred
more than a year after the procedure and resembled
migraine or thunderclap headache
1
.
Post-electroconvulsive therapy headache
Electroconvulsive therapy (ECT) is commonly used
in the treatment of various psychiatric disorders, such as
severe depression, schizophrenia, and bipolar disorders.
Headache is the main adverse effect resulting from this
therapeutic procedure. Its incidence varies from 26% to
85% and makes it difcult for the patient to continue with
this treatment
39
.
This headache occurs when a course of
electroconvulsive therapy (ECT) has been given in a
headache-free patient to treat an epileptic seizure. It is
necessary that headache has developed after ≥50% of
ECT sessions; each headache has developed within four
hours after ECT; and each headache has resolved within
72 hours after ECT. There have been no validation studies
of its diagnostic criteria. Currently, it is in the appendix
of ICHD-3 (A7.6.3), but it is not better accounted for by
another ICHD-3 diagnosis
1
.
Usually, post-ECT headache is treated with
analgesics and / or non-steroidal anti-inammatory
drugs, but other optional treatments are being described.
In some case reports, mirtazapine
39
and topiramate
40
were effective.
CONCLUSION
Some secondary headaches are due to
diagnostic and / or therapeutic procedures.
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