A Propensity-Score Weighted Analysis of Short-Term Corticosteroid Therapy for Refractory Pain Following Spontaneous Subarachnoid Hemorrhage

Abstract

Background and Objectives Corticosteroids are prescribed for refractory headache in patients with spontaneous subarachnoid hemorrhage (SAH) despite limited supporting evidence. We hypothesized that a short course of corticosteroids would reduce pain. Methods We reviewed all patients who received corticosteroids for refractory headache following spontaneous SAH within our institutional database. Pain was measured by a numeric rating scale (NRS) every two hours. The primary outcome was maximum daily NRS; secondary outcomes were the mean daily NRS and daily opioid consumption. Propensity scores were developed using potential predictors of corticosteroid use, including age, sex, pre-treatment 24-hour pain burden, and the number of analgesics being used to control pain. Inverse probability treatment weighting (IPTW) was used to balance baseline covariate distributions between patients receiving corticosteroids and control patients. Generalized estimating equations were used to analyze longitudinal NRS and oral morphine equivalents based on the weighted cohort. Results A total of 213 patients were included; mean (SD) age was 55 (13) years, 141/213 (66%) were female. 195/213 (92%) had a low clinical grade (i.e., Hunt-Hess 1-3). Seventy patients received corticosteroids prescribed on average on post-bleed day 5 (SD 3.3) with an average of 26 (SD 10) mg of dexamethasone over 48 hours. Patients receiving corticosteroids and controls were well balanced on baseline predictors of treatment status. After IPTW, we found that corticosteroid therapy reduced daily maximum pain NRS by 0.59 (SE=0.39, p=.12), 0.96 (SE =0.42, p=.02) and 0.91 (SE=0.46, p=.048) on days 1-3, respectively, after adjusting for control effects. The mean daily pain NRS and daily opioid use were non-significantly reduced in the three days following corticosteroid initiation after adjusting for control effects. Conclusion Short term corticosteroids only slightly reduced maximum pain severity after spontaneous SAH. Other analgesic strategies are required to manage refractory pain in this population.