Dialysis headache: characteristics, impact and cerebrovascular evaluation

Headache is one of the most frequent symptoms that occur during hemodialysis sessions. Despite the high prevalence of dialysis headache, it has been little studied.

Objective:

To evaluate the characteristics, impact and factors associated with dialysis headache. The behavior of the cerebral vasculature was also compared between patients with and without dialysis headache.

Methods:

This was a cross-sectional study. Consecutive patients who underwent hemodialysis were assessed through a semi-structured questionnaire, the Headache Impact Test (HIT-6), the Hospital Anxiety and Depression Scale and the Short Form-36 Health Survey (SF-36). Transcranial Doppler ultrasonography was performed in the first and fourth hours of hemodialysis.

Results:

A total of 100 patients were included; 49 of them had dialysis headache. Women (OR=5.04; 95%CI 1.95-13.04), younger individuals (OR=1.05; 95%CI 1.01-1.08), individuals with higher schooling levels (OR=3.86; 95%CI 1.4-10.7) and individuals who had spent longer times on dialysis programs (OR=0.99; 95%CI 0.98-1) had more dialysis headache (logistic regression). Individuals with dialysis headache had worse quality of life in the domains of pain and general state of health (56.9 versus 76.4, p=0.01; 49.7 versus 60.2, p=0.03, respectively). Dialysis headache was associated with significantly greater impact on life (OR=24.4; 95%CI 2.6-226.6; logistic regression). The pulsatility index (transcranial Doppler ultrasonography) was lower among patients with dialysis headache than among those without them.

Conclusions:

Dialysis headaches occur frequently and are associated with worse quality of life and patterns of cerebral vasodilatation.

Keywords:
Headache; Pain; Renal Dialysis; Anxiety; Quality of Life; Ultrasonography, Doppler, Transcranial

Characteristic		n (%)	mean (±SD)
Start	Insidious	39 (79.6%)
Start	Sudden	10 (20.4%)
Characteristic of headache	Throbbing	36 (73.5%)
	Pressing	11 (22.4%)
	Stabbing	2 (4.1%)
Intensity (VAS)			6.7 (±2.1)
Duration (minutes)			215.2 (±429.2)
Photophobia		18 (36.7%)
Phonophobia		21 (42.9%)
Worsening through exercise		9 (18.4%)
Nausea		24 (49%)
Vomiting		14 (28.6%)
Aura		3 (6.1%)
Autonomic signs		1 (2%)
Start of headache in relation to dialysis (hour)	First	1 (2%)
	Second	8 (16.3%)
	Third	16 (32.7%)
	Fourth	24 (49%)
Location	Bilateral	34 (69.4%)
	Unilateral	9 (18.3%)
	Sometimes unilateral and sometimes bilateral	6 (12.2%)
Headache pattern - n (%)	Tension-type	26 (53.1%)
	Migraine	22 (44.9%)
	Tension-type or migraine	1 (2%)
Medication used during dialysis headache attack	Dipyrone	34 (69.4%)
	Paracetamol	8 (16.3%)
	Dipyrone/paracetamol	4 (8.2%)
	Others	3 (6.1%)
Dialysis headaches over the last 30 days		26 (53.1%)
Number of sessions with headaches over the last 30 days			2 (±2.8)
Length of time until end of headache after end of dialysis (minutes)			180.4 (±421.1)
Behavior of headache intensity over the months	Same as in the beginning	12 (24.5%)
	Becoming more intense	9 (18.4%)
	Becoming less intense	28 (57.1%)
Behavior of headache frequency over the months	Same as in the beginning	7 (14.3%)
	Becoming more frequent	9 (18.4%)
	Becoming less frequent	33 (67.3%)

Characteristics		With dialysis headaches	Without dialysis headaches	p-value	Odds Ratio (95%CI)	p-value
Characteristics		n=49	n=51	(Univariate analysis)	(Logistic regression)	(Logistic regression)
Age (years): median (IQR)		45 (39-58.9)	56 (49.5-64)	<0.01	1.05 (1.01-1.08)	<0.01
Sex	Female	34 (69.4%)	16 (31.4%)	<0.01	5.04 (1.95-13.04)	<0.01
Sex	Male	15 (30.6%)	35 (68.6%)		Reference value
Schooling level	Up to 7 years	11 (22.5%)	26 (51%)	0.07	Reference value	0.02
Schooling level	≥8 years	38 (77.5%)	25 (49%)		3.86 (1.4-10.7)
Length of time on hemodialysis (months): median (IQR)		36 (17-96)	24 (11-48)	0.13	0.99 (0.98-1)	0.04
Migraine		17 (34.7%)	8 (15.7%)	0.03	-	-
Tension-type headache		22 (44.9%)	29 (56.9%)	0.23	-	-
Excessive use of caffeine		3 (6.1%)	4 (7.8%)	0.73	-	-
Anxiety		18 (36.7%)	10 (19.6%)	0.06	-	-
Depression		14 (28.6%)	11 (21.6%)	0.42	-	-

Characteristics		High impact from headache	Low impact from headache	p-value	Odds Ratio (95%CI)	p-value
		(HIT-6>55)	(HIT-6<56)	(Univariate analysis)	(Logistic regression)	(Logistic regression)
		n=21	n=79
Age (years): median (IQR)		45 (38-53.5)	55 (44.5-61.5)	0.07	-	-
Sex	Female	18 (85.7%)	32 (40.5%)	<0.01	-	-
Sex	Male	3 (14.3%)	47 (59.5%)	<0.01	-	-
Length of time on hemodialysis (months): median (IQR)		35 (20.5-78)	27 (12-78)	0.49	-	-
Migraine		11 (52.4%)	14 (17.7%)	0.02	-	-
Tension-type headache		7 (33.3%)	44 (55.7%)	0.07	-	-
Excessive use of caffeine		2 (9.5%)	5 (6.3%)	0.61	-	-
Anxiety		13 (61.9%)	15 (19%)	<0.01	8.8 (1.9-40.8)	<0.01
Depression		9 (42.9%)	16 (20.3%)	0.04
Dialysis headache		20 (95.2%)	29 (36.7%)	<0.01	24.4 (2.6-226.6)	<0.05

	With dialysis headache	Without dialysis headache	p-value
	(Mean ±SD)	(Mean ±SD)	p-value
MFV of right MCA in 1^st hour of dialysis (n=83)	51.30 (±14.2)	46 (±12.2)	0.13
MFV of left MCA in 1^st hour of dialysis (n=83)	51.40 (±16.3)	47 (±12.8)	0.38
MFV of right MCA in 4^th hour of dialysis (n=83)	45.60 (±16.8)	41.4 (±10.9)	0.55
MFV of left MCA in 4^th hour of dialysis (n=83)	43.20 (±15.2)	41.9 (±13.4)	0.98
PI of right MCA in 1^st hour of dialysis (n=83)	0.97 (±0.25)	1.1 (±0.26)	0.01
PI of left MCA in 1^st hour of dialysis (n=83)	0.99 (±0.31)	1.09 (±0.25)	0.02
PI of right MCA in 4^th hour of dialysis (n=83)	1.08 (±0.3)	1.2 (±0.42)	0.13
PI of left MCA in 4^th hour of dialysis (n=83)	1.04 (±0.33)	1.21 (±0.41)	0.02

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[1] Correspondence: Pedro Augusto Sampaio Rocha Filho; Email: pedroasampaio@gmail.com.