1403 - Headache After the Hemorrhage: Post-Subarachnoid Hemorrhage Headache Management in Inpatient Rehabilitation

Case Diagnosis: A 59-year-old male developed persistent post-subarachnoid hemorrhage (SAH) headache following bilateral parietal SAH and bilateral contusions. His exertion-induced headaches significantly interfered with inpatient rehabilitation progress, highlighting the challenge of managing post-SAH headache in rehabilitation settings where standardized guidelines are lacking and effective multimodal management strategies remain underrecognized.

Case Description: The patient presented with altered mental status; imaging confirmed bifrontal contusions and bilateral parietal SAH without midline shift. He was transferred to inpatient rehab on hospital day 7 with impaired balance, impulsivity, cognitive deficits, and exertion-related bifrontal headaches. Acetaminophen-codeine provided minimal relief. A multimodal regimen was implemented: gabapentin (1200 mg/day), activity pacing, postural training, and environmental modifications. Over two weeks, his headaches decreased, therapy tolerance improved, and functional mobility advanced from moderate assistance to 800 feet ambulation with contact guard. Cognitive endurance gains also improved speech therapy participation.

Discussions: Post-SAH headache is multifactorial, with proposed mechanisms including central sensitization, cortical spreading depolarizations, neuroinflammation, and possible NMDA receptor-mediated excitotoxicity. Despite frequent use, opioids are often ineffective and pose safety risks. This case illustrates the role of physiatrists in leading an interdisciplinary, opioid-sparing strategy combining gabapentinoids, behavioral pacing, and physical modalities to target central sensitization and functional barriers. By reducing symptom burden, patients can better engage in therapy. Addressing headache not merely as pain, but as a barrier to rehabilitation, is essential to optimize recovery and independence.

Conclusions: Effective headache management is essential to optimize outcomes after SAH. A tailored, multimodal, opioid-sparing approach can enhance participation, functional recovery, and quality of life. Physiatrists are uniquely positioned to implement these strategies, bridging neuroscience, pharmacology, and rehabilitation therapies. This case supports the need for further research and consensus on guideline-based management of post-SAH headache in rehabilitation populations.