Objectives To predict which patients with intracranial endovascular coiling develop headaches (HA), the utility of neuroimaging in these patients and to investigate whether triptans and ergots can be safely used for migraine in the setting of pre- and post-coiled aneurysms.
Background Excessive diagnostic testing is often obtained in patients with prior intracranial endovascular coiling who present with HA. Results are frequently low yield with unnecessary risks and costs. The ability to predict those most likely to develop post-coiling HA would help decrease these risks and costs. Lastly, pre- and post-coiled aneurysms are often considered a contraindication for triptan and ergot use, although supporting data are lacking.
Methods Retrospective chart review. Inclusions: men/women >18 years with intracranial endovascular coiling at the Cleveland Clinic from July 2006 to June 2009. Exclusions: age <18 years, craniotomy, external ventricular devices, extracranial procedures, intracranial neoplasms, lack of follow-up. Outpatient/inpatient visits and telephone encounters reviewed by electronic medical records for demographics, procedures, materials, coiling indication (emergent/elective), lesion location/size, pre/post-coiling HA, triptan or dihydroergotamine (DHE) use.
Results 264 patient were reviewed (202 females, 62 males).
72%; 190/264 (155F: 82% of HA, 77% of F) (35M: 18% of HA, 57% of M).
Anterior circulation: 146/190, posterior circulation: 46/190.
HA pre-emergent coiling: 73%; 43/59 (38F, 5M).
HA pre-emergent coiling with no HA post-coiling: 16/59 (9F, 7M).
HA <1 year pre-elective coiling: 85%; 71/84 (54F, 17M).
HA <1 year pre-elective coiling with no HA post-coiling: 13/84 (8F, 5M).
HA >1 year pre-coiling: 89%; 46/52 (38F, 8M).
HA >1 year pre-coiling with no HA post-coiling: 6/52 (6F, 0M).
No HA pre-elective coiling: 48%; 37/77 (32F, 5M).
Urgent procedures: 118; non-contrast CT 69; CTA 7; MRI/A/V 29; cerebral angiogram five; LP eight (one required blood patch); all negative except one with small acute finding.
Triptans used safely in 10 pre-coiling and 10 post-coiling patients, and DHE in one post-coiling patient.
Post-coiling HA comorbidities Smokers: 57%; 108/190.
(87F: 81% total smokers with HA, 56% total women with HA, 46% total HA).
(21M: 19% total smokers with HA, 60% total men with HA, 11% total HA).
Depression/anxiety: 48%; 92/190.
(78F: 85% total anxiety/depression with HA, 50% total women with HA, 41% total HA).
(14M: 15% total anxiety/depression with HA, 40% total men with HA, 0.07% total HA).
Smokers and/or anxiety/depression: 75%; 142/190.
(115F: 81% total smokers and/or anxiety/depression with HA, 74% total women with HA, 61% total HA).
(27M: 19% total smokers and/or anxiety/depression with HA, 77% total men with HA, 14% total HA).
Conclusions HA frequently follows intracranial endovascular coiling. Post-coiling HA occurs more commonly in women, and this risk is magnified in patients who smoke or have comorbid psychiatric disease. These findings may help predict those most likely to develop post-coiling HA. Diagnostic testing for acute post-coiling HA is low yield and may pose unnecessary costs and risks. Triptans and DHE (an ergot) were used safely in a small number of patients pre- and post-coiling. Many pre-coiling HAs resolved post-coiling, suggesting that aneurysmal coiling may resolve HAs in select patients. More data are needed to further prospectively evaluate these trends.
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Competing interests ST—Clinical Research: ATI, GSK, MAP, Merck; Consultant: GSK, Merck, MAP, Nupathe, Zogenix; Honoraria: GSK, Merck.