Randomized Trial for Pain Management in Low-grade Subarachnoid Hemorrhage

Headaches associated with subarachnoid hemorrhage (SAH) cause severe pain. Headache
management is complex, requiring a balance between pain control and preservation of
neurological assessment. Sufficient pain control can be achieved with narcotics, however,
these carry numerous undesirable side effects. Most critically, all narcotics can result in
respiratory depression and sedation. For patients who present without neurological defects
but debilitating pain, management is particularly challenging. The sedative effect of
narcotics confounds the management of these patients by interfering with the neurological
examination. Pain management is also a significant concern for patient's families as they
observe suffering without full understanding of the importance of preserved mental status.
In order to control the pain associated with SAH headaches, the use of narcotics is often
required despite the risks. This standard therapy involves an IV bolus dose delivered by the
provider regularly as needed for pain control. A common approach to reduce pain in other
patient populations, including acute pain relief following major spine surgery, is patient
controlled analgesia (PCA). With the PCA method, patients deliver low doses of narcotics
through a pain pump with preset maximal doses and frequency of delivery. We hypothesize that
this approach to pain relief for SAH headaches will result in lower pain scores, greater
patient and family satisfaction scores, and increased patient safety with lower narcotic
doses minimally interfering with neurological assessment.