Is Low Blood Magnesium Level Associated With Hemodialysis Headache?

Prevention and resolution of headaches occurring during hemodialysis treatment by supplemental oxygen

A patient with end-stage renal disease experienced severe headaches exclusively during dialysis that were bilateral and throbbing with photophobia, weakness, and lightheadedness. The patient had no history of headaches, and dialysis was determined to be the cause of the severe headaches. More than 10 treatments were attempted without success. Headaches were successfully treated and prevented by addition of 100% oxygen (2 L via nasal cannula) for over 12 months without recurrence at time of publication. This case study indicates that oxygen therapy may be a valuable intervention for headaches during dialysis.

Headaches Attributed to Disorders of Homeostasis

Headaches attributed to disorders of homeostasis include those different headache types associated with metabolic and systemic diseases. These are headache disorders occurring in temporal relation to a disorder of homeostasis including hypoxia, high altitude, airplane travel, diving, sleep apnea, dialysis, autonomic dysreflexia, hypothyroidism, fasting, cardiac cephalalgia, hypertension and other hypertensive disorders like pheochromocytoma, hypertensive crisis, and encephalopathy, as well as preeclampsia or eclampsia. The proposed mechanism behind the causation of these headache subtypes including diagnostic criteria, evaluation, treatment, and overall management will be discussed.

Low pulse pressure and high serum complement C1q are risk factors for hemodialysis headache: A case-control study

BACKGROUND AND OBJECTIVE

Hemodialysis headache (HDH) is a common complication of dialysis that negatively affects the patient's quality of life. The etiology and triggering factors of HDH are not fully understood. This study aims to assess the prevalence and characteristics of HDH among patients undergoing hemodialysis across multiple centers in China. Furthermore, we conducted a case-control study at one hospital to identify risk factors associated with HDH.

METHODS

The study consisted of two phases including a cross-sectional observational study and a case-control study. Participants underwent neurological examinations and interviews. Demographic and medical information were collected from both medical records and patient files. Serum creatinine, uric acid, urea, estimated glomerular filtration rate (eGFR), plasma osmolarity, glucose, C1q, and a variety of electrolytes including potassium, sodium, chloride, calcium, magnesium, and phosphorus were measured before and after dialysis. Blood pressure variables including systolic blood pressure, diastolic blood pressure, pulse pressure (PP), and heart rate were monitored hourly. Serum levels of inflammatory factors, including tumor necrosis factor α (TNF-α), interleukin (IL)-1β, IL-4, IL-6, and IL-10 were quantified using a double-antibody sandwich enzyme-linked immunosorbent assay (ELISA).

RESULTS

The prevalence of HDH was 37.7% (183/485). HDH was characterized by a bilateral tightening headache of moderate intensity and duration of <2 h, occurring in different locations. The case-control study included 50 patients with HDH and 84 control patients, pre-dialysis PP was found to be lower in the HDH group than in the control group (mean ± standard deviation 51.5 ± 18.2 vs. 67.9 ± 14.9, p = 0.027). Furthermore, the pre-dialysis serum complement C1q level was significantly higher for the HDH group than the control group (median and interquartile range 201.5 [179.0-231.5] vs. 189.0 [168.9-209.0], p = 0.021). Pre-dialysis PP was associated with 5.1% decreased odds of HDH (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.93-0.99, p = 0.026), body weight was associated with a 5.4% decreased risk of HDH (OR = 0.95; 95% CI, 0.91-0.99, p = 0.013), and pre-dialysis C1q levels increased the odds of HDH by 1.9% (OR = 1.02; 95% CI, 1.01-1.03, p = 0.005).

CONCLUSION

Low PP, low body weight, and high blood complement C1q may be potential risk factors associated with HDH.

Association of intradialysis blood sodium level, blood pressure variability, and hydration status with hemodialysis-related headache: a prospective cohort study

OBJECTIVE

To identify primary factors contributing to hemodialysis-related headache (HRH) in maintenance hemodialysis (MHD) patients.

METHODS

Adult outpatients receiving MHD were prospectively enrolled from a hemodialysis (HD) center of a tertiary hospital in China. Twelve dialysis sessions were successively monitored for each patient. HRH is defined as having at least three headache episodes that begin during HD and resolve within 72 h of HD session completion. Blood gas analysis during headache episodes and body composition analysis after dialysis were conducted. Hour-to-hour vital sign variability during dialysis was assessed using the metric of average real variability (ARV). Multivariable logistic regression analysis was conducted to explore the factors triggering HRH.

RESULTS

A total of 95 Chinese MHD patients were enrolled, with 92 patients (60.9% were males) included in the final analysis. The mean age of the 92 patients was 59.3 ± 17.5 years, and the median dialysis vintage was 27.1 (12-46.2) months. Among them, 12 patients (13%) complained of 42 headache attacks, and eight (8.7%) were diagnosed with HRH. For eight patients with HRH, headache occurred 100.3 ± 69.5 min after the start of dialysis, with a mean VAS score of 4.3 ± 1 points. The quality of headaches was dull (six patients), pulsating (one patient), or stabbing pain (one patient); all the headaches were bilateral, with one having concomitant vomiting. The intradialysis headache duration and the whole headache duration were 98.8 ± 68.1 and 120 (65-217.5) minutes, respectively. Younger age (OR = 0.844, 95% CI 0.719-0.991, p = 0.039), decreased blood sodium level (OR = 0.309 in the range of 133-142 mmol/L, 95% CI 0.111-0.856, p = 0.024), increased ARV of intradialysis systolic blood pressure (OR = 3.067, 95% CI 1.006-9.348, p = 0.049) and ratio of overhydration to dry weight (OR = 1.990, 95% CI 1.033-3.832, p = 0.040) were found to be independent risk factors for HRH.

CONCLUSIONS

This study suggested a significant attribution of blood sodium, hydration status and blood pressure variability to HRH.

The applicability research of the diagnostic criteria for 10.2 Heamodialysis-related headache in the international classification of headache disorders-3rd edition

BACKGROUND

Headache during hemodialysis (HDH) is prevalent but not negligible. Despite the high prevalence of dialysis headaches, they have rarely been studied. Therefore, this study aimed to evaluate the prevalence, risk factors, and clinical characteristics of HDH and reappraise the HDH diagnostic criteria in the International Classification of Headache Disorders 3 (ICHD-3).

METHODS

One hundred and fifty-four patients completed this randomized cross-sectional study. Consecutive patients who underwent haemodialysis were assessed using a semi-structured questionnaire. The patients were administered face-to-face questionnaires while undergoing dialysis.

RESULTS

This study included 154 patients. Before commencing dialysis, 3.24% (5/154) of the patients had migraine without aura, 1.29% (2/154) had menstrual-related migraine, 0.6% (1/154) had tension-type headaches, and 0.6% (1/154) had an unclassifiable headache. One case (0.6%) of headache resolved after dialysis treatment. HDH was diagnosed in 9.09% (14/154) of the patients. Headache after haemodialysis (HAH) was reported in 6.49% (10/154) of patients. The most prevalent features of HDH were frontal or temporal location, bilateral headaches, dull and throbbing nature, and moderate severity. HDH started at a mean of 2.33 ± 0.79 h after dialysis commenced. The average headache duration was 6.56 ± 1.57 h (median = 3.0 h), with 66.67% of the patients reporting a duration of ≤4 h. HDH was more prevalent in females than males (P = 0.01, P < 0.05). Female sex was a risk factor for HDH (P = 0.01，P < 0.05).

CONCLUSIONS

The diagnostic criteria for 10.2 HDH in ICHD-3 may miss several HAH. Therefore, ICHD-3 should be revised according to the literature and further studies.

Dialysis headache: A literature review in the last 30 years

Introduction According to the International Classification of Headache Disorders (ICHD-3), dialysis headache has no specific characteristics occurring during and caused by haemodialysis. It resolves spontaneously within 72 hours after the haemodialysis session has ended. Objective To describe the prevalence, clinical features, associated symptoms and risk factors of dialysis headache. Methods Based on a literature search in the major medical databases and using the descriptors“dialysis headache”, “hemodialysis and headache” and “renal dialysis and headache”we included articles published between 1992 and 2022. Of the 492articles found, only 9 met the inclusion criteria and were analyzed. Results We describe 444 patients (53.1% men and 46.9% women) diagnosed with dialysis headache, corresponding to 24.8% of those who underwent hemodialysis.The age ranged from 15 to 75 years. Pain occurred predominantly from the third hour of hemodialysis (65.8%), lasting less than four hours (71.7%), located bilaterally (63.1%), pulsatile (58.5%) and moderate intensity (68.9%).The most frequent associated symptoms were photophobia or phonophobia (71.5%), vertigo (22.3%) and nausea and/or vomiting (16.5%). Conclusion This review showed a high prevalence of dialysis headache in patients undergoing hemodialysis and that the clinical characteristics, treatment and prevention are still poorly studied.

Dialysis headache: characteristics, impact and cerebrovascular evaluation

ABSTRACT Background: 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.

Effects of Caffeinated and Decaffeinated Coffee on Hemodialysis-Related Headache (CoffeeHD): A Randomized Multicenter Clinical Trial

OBJECTIVES

Historically, headache was reported in up to 76% of hemodialysis patients. Some authors suggested that headache resulted from caffeine withdrawal. This study aims to compare the incidence of headache and hypotension between patients drinking regular or decaffeinated coffee during dialysis.

METHODS

One-hundred fifty-six patients were enrolled in this randomized, double-blind, placebo-controlled, multicenter study. Patients with atrial fibrillation were excluded. Group A was given 80 mL of regular coffee and group B 80 mL of decaffeinated coffee (placebo) in the middle of the session for 12 consecutive sessions. Ultrafiltration rate was fixed to a maximum of 13 mL/kg/hour. The primary outcome was the incidence of headache during dialysis.

RESULTS

A total of 139 patients completed the trial (6.4% vs. 15.4% of withdrawal in Groups A and B, respectively). The number of sessions with headache was not significantly different between Group A and B (33.3% vs. 37.1% respectively, P = .522), nor the number of sessions with hypotension (27% vs. 26% respectively, P = .539). In a subgroup analysis, headache tended to be more frequent in Group B (P = .06) in 2 categories of patients: those with the highest potassium dialysate (K = 2) and the non-hypertensive patients.

CONCLUSIONS

Headache occurred in 35% of patients during their chronic hemodialysis sessions. Caffeine intake did not prevent headache occurrence in these patients.

Hemodialysis-related headache: Still a challenge in 2020? Effect of conventional versus online hemodiafiltration from a study in Casablanca, Morocco

Hemodialysis-related headache (HRH) is a well-known clinical event. It is considered as one of the most commonly reported neurological symptoms among hemodialysis patients. Its epidemiological, physiological, clinical, and therapeutic data remain scarce and are poorly studied. Our aim was to determine the frequency of HRH in the region of Casablanca, Morocco, to describe its clinical characteristics and to explore the hypothesis that renal replacement techniques, such as conventional versus online hemodiafiltration may have an association on clinical adverse effects like HRH. A descriptive, cross-sectional, and multicentric study was carried out among 100 chronic hemodialysis patients for at least 6 months. HRH was defined according to criteria published by the International Classification of Headache Disorder third edition beta version (ICHD3β) [1]. Two different HD-modalities (standard HD and OL-HDF) have been investigated in order to explore their impact on HRH. Headache was reported by 60% of the patients including 41.6% of hemodialysis-related headache. HRH had on average a duration of 7.4 hours, pulsatile among 38% of interviewed patients and of moderate intensity in 48% of cases. In total, 51.3% of patients undergoing conventional hemodialysis modality reported HRH compared to 12.5% undergoing online hemodiafiltration technique (OL-HDF) (P = .008). Hemodialysis-related headache remains a poorly studied clinical event despite its high prevalence. Its diagnosis, management, and especially its prevention remain a challenge for the neurologist and the nephrologist. Our results suggest that OL-HDF is a promising therapeutic and preventive tool to reduce the incidence of HRH.

New-onset hemodialysis-related headache presenting as migraine aura

Hemodialysis headache (HDH) is an infrequent new-onset symptom, occurring mainly in old uremic patients. Type of pain is nonspecific, occurs during hemodialysis treatment, assuming features similar to tension-type headache and representing a problem, also as regards the therapy to be taken. International Headache Society (IHS) has placed this form of headache among the headaches disorders of homeostasis. We found a case of new-onset HDH in old uremic man, presenting with migraine aura features. A similar case has not been reported in literature, placing us some questions: why and how does this happen? What are the mechanisms involved? Role of trigeminal-vascular system and cortical spreading depression as regards the aura could be considered, through the activation of neuroinflammatory events, lastly causing migraine aura. Moreover, the administration of flunarizine strongly improved migraine symptoms in our patient, as happens in migraine syndromes. Definitely, this case leads us to think that some mechanisms involved in headaches will need to be further clarified.

Headache in pediatric and adolescent patients with chronic kidney disease, with and without hemodialysis: A comparative cohort study

Background Several studies have reported dialysis-related headache in adults. We investigated headache and its characteristics in pediatric and adolescent patients with chronic kidney disease and patients treated with dialysis, and compared characteristics of patients with and without headache in the entire cohort and separately among dialysis and among chronic kidney disease patients. Methods Patients and their parents who attended a nephrology clinic and hemodialysis unit were interviewed regarding the existence of headache and its characteristics. We reviewed hospital files for medical history, blood test results, and pharmacologic treatment. Headache was defined according to International Headache Society criteria. Results The cohort comprised 60 patients: 39 with chronic kidney disease without hemodialysis and 21 treated with hemodialysis; 39 were males, mean age 11.9 ± 5.3 years. Twenty-six (43.3%) reported experiencing headaches. The hemodialysis group had a higher rate of headache than the chronic kidney disease patients, at 76.2% vs. 25.5%, p < 0.001. In the hemodialysis group, 15 out of 16 reported dialysis-related headache; 14 (87.5%) of these had migraine characteristics. For the entire cohort, headache was associated with hemodialysis, chronic kidney disease grade, lower glomerular filtration rate anemia and a higher parathyroid hormone level. In logistic regression analysis, glomerular filtration rate was significantly associated with headache, odds ratio 2.74 (95% CI 1.56-4.82, p < 0.001). Conclusions A high rate of headache, mostly migraine type, was reported by hemodialysis patients. Hemodialysis, anemia, higher parathyroid hormone levels, phosphate, and lower glomerular filtration rate are strongly associated with headache among chronic kidney disease pediatric and adolescent patients.

Serum concentration of magnesium as an independent risk factor in migraine attacks: a matched case-control study and review of the literature

There is controversy over the role of magnesium in the etiology of migraine headaches. We aimed to evaluate and compare serum levels of magnesium between healthy individuals and those with migraine headaches during migraine attacks and between attacks to evaluate the role of magnesium in the etiology of migraine headaches. Forty patients with migraine headaches and 40 healthy individuals were enrolled in this matched case-control study. Malnutrition, digestive system disorders, history of smoking, drug abuse, and history of medications use were recorded at baseline. The pain scores of patients were measured and recorded based on a 10 cm visual analog scale. Subsequently, blood samples were collected at 8-10 in the morning to determine serum levels of magnesium. Analysis of variance, χ-test, and conditional logistic regression were used for data analysis. There were no significant differences in demographic data between the two groups. There were significant differences in magnesium serum levels between the three groups (1.09±0.2 mg/dl during migraine headaches; 1.95±0.3 mg/dl between the attacks; and 1.3±0.4 mh/dl in the control group; P<0.0001). Odds of acute migraine headaches increased 35.3 times (odds ratio=35.3; 95% confidence interval: 12.4-95.2; P=0.001) when serum levels of magnesium reached below the normal level. The odds in patients who are not in the acute attack phase were 6.9 folds higher (odds ratio=6.9; 95% confidence interval: 1.3-2.1; P=0.02). The serum level of magnesium is an independent factor for migraine headaches and patients with migraine have lower serum levels of magnesium during the migraine attacks and between the attacks compared with healthy individuals.

Dialysis Headache: A Narrative Review

BACKGROUND

Patients with chronic kidney disease who need dialysis often have poor quality of life. Dialysis headache is a frequent complication of hemodialysis and is often a challenge for nephrologists, neurologists, and headache specialists.

METHOD

This was a narrative review.

RESULTS

The prevalence of dialysis headache varies between 27% and 73%. Among the characteristics of this headache are the pulsatile pattern, frontal location, moderate to severe intensity, and onset a few hours after the beginning of dialysis. The headache may be accompanied by nausea and vomiting. The physiopathology of hemodialysis headache is still not completely understood. Some factors that seem to be associated with it are variations in urea, sodium, magnesium, blood pressure, and weight levels. The hematoencephalic barrier has an important role. Variations in electrolyte and urea levels occur in the systemic circulation during hemodialysis, but the cerebral concentrations of these substances are stable over the first few hours of the procedure. The flow of free water through the hematoencephalic barrier may lead to cerebral edema. Other potential pathophysiological factors include nitric oxide, calcitonin gene-related peptide, and substance P. There are recommendations for maintenance of volume and control over electrolytes and blood pressure and avoidance of caffeine for prevention of hemodialysis headache. However, there are no controlled studies of prophylactic or abortive hemodialysis headache treatment.

CONCLUSION

Despite its prevalence, hemodialysis headache has been poorly studied, thus making it difficult to understand the pathophysiological mechanisms involved in its genesis. Current clinical management practices are therefore necessarily empiric with minimal to no evidence base.

Prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent hemodialysis: a systematic review

OBJECTIVES

Understanding the epidemiology of pain in patients on hemodialysis (HD) is crucial for further improvement in managing pain. The aim of this study was to systematically review available evidence on the prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent HD.

MATERIALS AND METHODS

We carried out a systematic review of the literature and developed a comprehensive search strategy based on search terms on pain and HD. We searched the databases MEDLINE, Scopus, PsycINFO, and CINAHL from the earliest date of each database to July 24, 2014. Manuscripts in all languages were taken into consideration. Two authors performed each step independently, and all disagreements were resolved after discussion with the third author. The quality of studies was estimated using the STROBE checklist and Cochrane risk-of-bias tool.

RESULTS

We included 52 studies with 6,917 participants. The prevalence of acute and chronic pain in HD patients was up to 82% and 92%, respectively. A considerable number of patients suffered from severe pain. Various locations and causes of pain were described, with most of the studies reporting pain in general, pain related to arteriovenous access, headache, and musculoskeletal pain.

CONCLUSION

The findings of this systematic review indicate high prevalence of pain in HD patients and considerable gaps and limitations in the available evidence. Pain in this population should be recognized as a considerable health concern, and the nephrology community should promote pain management in HD patients as a clinical and research priority to improve patients' quality of life and pain-related disability.

An Approach to Pain Management in End Stage Renal Disease: Considerations for General Management and Intradialytic Symptoms

The prevalence and severity of symptoms in patients with advanced chronic kidney disease is higher than those of the general population and comparable to those with other chronic and serious medical conditions. Despite the prevalence and severity in this population, symptoms continue to be under-recognized and inadequately managed. The recognition of specific intradialytic pain syndromes such as pain related to arteriovenous access, headaches, muscle cramps or generalized pain by providers may aid in improving patient compliance and quality of life. The approach to pain management in end stage renal disease patients follows that of the general population with specific considerations regarding clearance and potential side effects guiding selection of agents. Overall, evidence is limited regarding the pharmacology of many medications in this population.

Headache during haemodialysis in a patient with shunt: a cause for concern?

A 20-year-old woman with a functioning ventriculoperitoneal (VP) shunt consistently reported unbearable vertex headaches and nausea during the last hour of her haemodialysis (HD) sessions. After one particularly severe episode, which was associated with vomiting, restlessness and blurred vision, her team suspected that she was developing dialysis disequilibrium syndrome. She improved fully on cessation of HD, requiring simple analgaesia only, and continued dialysis three times per week. Several more distressing episodes of nausea and headaches compelled us to give intravenous mannitol during HD, resulting in temporary improvement. Subsequently, shorter and more frequent dialysis sessions along with intravenous mannitol resulted in satisfactory clinical response.

Hemodialysis-related headache

Headache is one of the most frequently encountered neurological symptoms during hemodialysis. According to International Classification of Headache criteria dialysis-related headache was defined as the headache occurring during hemodialysis with no specific characteristic. It resolves spontaneously within 72 hours after the hemodialysis session ends. There are few studies in the literature investigating the clinical features of dialysis headache. The pathophysiology of hemodialysis-related headache is not known, but various triggering factors have been identified, including changes in blood pressure, serum sodium and magnesium levels during hemodialysis sessions, caffeine deprivation and stress. The aim of this article is to evaluate and analyze features of headache in patients undergoing hemodialysis.

Metabolic headaches

This article discusses headaches secondary to disorders of homeostasis, which include headaches attributed to (1) hypoxia and/or hypercapnia (high-altitude, diving, or sleep apnea), (2) dialysis, (3) arterial hypertension (pheochromocytoma, hypertensive crisis without hypertensive encephalopathy, hypertensive encephalopathy, preeclampsia or eclampsia, or autonomic dysreflexia), (4) hypothyroidism, (5) fasting, (6) cardiac cephalalgia, and (7) other disorder of homeostasis. Clinical features and diagnosis as well as therapeutic strategies are discussed for each headache type.

Beneficial Effects of Magnesium Supplementation

Magnesium is an essential mineral necessary for optimal cellular health and well-being. Many adults in the United States fail to get recommended amounts of magnesium from their diets. Even so, symptoms of magnesium deficiency are rarely seen; however, maintaining normal body stores could be preventative against common diseases.

Review: modelling the dialysate

Dialysate prescription is evolving as new technology allows greater opportunity to alter dialysate constituents throughout dialysis, providing scope for tailored prescription for an individual patient. The intention of modelling or profiling is to improve the tolerability of dialysis and long-term patient outcomes. This approach can be applied to both electrolytes and water. Despite these advances in technology, benefits of modelling have not been demonstrated consistently. This review examines the use of individual prescription and modelling of dialysate sodium, ultrafiltrate, potassium, calcium, magnesium, bicarbonate and phosphate.

Clinical description of hemodialysis headache in end-stage renal disease patients

BACKGROUND

Hemodialysis (HD)-related headaches are a common complaint of patients undergoing this procedure.

OBJECTIVE

To determine the frequency and clinical characteristics of headache in patients undergoing HD and to discuss their diagnostic criteria.

METHOD

The present study assessed, in a prospective manner, a series of patients consulting at a HD center in Aracaju, Sergipe, Brazil, from November 2007 to January 2008. Only patients with HD-related headaches without previous history of primary headache were diagnosed as isolated HD headache (HDH).

RESULTS

Headache was reported by 76.1% of the patients studied. Prior to beginning dialysis, 47.9% had migraine without aura, 6.7% migraine with aura, 0.6% hemiplegic migraine, 5% episodic tension-type headache, and 2.5% migraine and tension-type headache. HDH was diagnosed in 6.7% of the patients, the most prevalent features being diffuse or temporal region location, bilateral headache, throbbing nature, and moderate severity. Seven patients with headaches between the sessions were not classified.

CONCLUSION

While the pathophysiology of HDH is unknown, to diagnose patients with HDH or other possible HD-related headaches remains a challenge.

[Headache associated with haemodialysis]

INTRODUCTION

Haemodialysis (HD) is one of the most accessible methods for the treatment of the growing number of patients suffering from terminal-stage renal insufficiency. Although headache is the most frequently encountered neurological symptom during HD, there are few studies reporting its prevalence and clinical features.

OBJECTIVE

The objective of this study was to examine the frequency, demographic and clinical features of headache during HD, and to compare these parameters among patients with and without headache.

METHOD

The study involved 126 patients (48 female and 78 male) with chronic renal failure on regular HD for at least six months, at the Dialysis Unit of Nephrology Department, Krusevac. All patients were inquired about their possible problems with headache using the standardized questionnaire designed according to the diagnostic criteria of the International Headache Classification of Headache Disorders, second edition, published in 2004 (ICHD-II). Subsequently, the patients were clinically evaluated and patients with headaches were further subclassified by a neurologist with special interest in headache disorders. Patients with headache were compared to the patients without headache regarding age, sex, duration of HD, causes of end-stage renal disease, arterial diastolic and systolic blood pressure, and serum values of the most important blood parameters such as sodium, potassium, urea and creatinine. In the group of patients with headache we analyzed the characteristics of specific headache type according to ICHD-II classification. We also analyzed the most important clinical features of haemodialysis headache (HDH).

RESULTS

In the group of 126 evaluated patients, 41 (32.5%) patients had headaches. There were no statistically significant differences between the patients with headaches and those without headaches regarding sex, age, BMI, duration of HD, causes of end-stage renal disease, arterial blood pressure, red blood cell count, serum concentration of haemoglobin, blood urea nitrogen, creatinine, glucose, MCHC, total protein, sodium and potassium. Fourteen patients (34% of those with headaches) experienced headache during the HD session and were subclassifled as HDH using diagnostic criteria of the International Headache Society. Tension type headache (41% of those with headaches) and migraine without aura (10%) were most common in the primary headache group and headache due to arterial hypertension (7%) was the most prevalent among the secondary headaches. Although there were some common clinical characteristics, we could not find a unifying clinical pattern in the patients with HDH.

CONCLUSION

Haemodialysis headache is the most common headache in patients undergoing haemodialysis, and despite some common symptoms, it does not appear to be uniform in its clinical characteristics.

Dialysis headache

We describe the various side effects occurring in dialysis sessions and indicate measures for their prevention and/or treatment. Next, we analyze dialysis headache in terms of incidence, prevalence, criteria for its inclusion in the classification of the International Headache Society, and factors related to its triggering, ie, bradykinin and nitric oxide (NO), which have increased plasma levels during dialysis. This permits a critical analysis in comparison with NO donor headache in terms of the pathophysiologic mechanisms that mediate the triggering of both conditions. A similarity is particularly detected in terms of the role of NO as the last link in the chain of events that precedes the onset of headache, which is preceded by a latency period of 3 to 4 hours, much longer than the few seconds needed to inactivate NO. A hypothesis is raised to explain this phenomenon, opening new perspectives for the study of the pathophysiology of headaches, including primary headaches.

[Hemodialysis-related headaches]

BACKGROUND/AIM

Hemodialysis (HD) is a therapeutic procedure used to partially correct homeostatic disorders and prevent complications of uremia to appear in the terminal stage of renal insufficiency. The aim of this study was to evaluate and analyze the incidence and features of haedaches in patients undergoing hemodialysis.

METHODS

A total of 143 patients, 50 women and 93 men, undergoing hemodialysis, were questionned about their problems with headache using a questionnary designend according to the diagnostic criteria of the Intemational Headache Classification of Headache Disorders from 2004. The patients were separated into two groups: the patients without headache and the patients with repeated headaches. Afterwards, the patients with headaches were further divided into subgroups: the patients who had the headaches before the beginning of HD and patients who experienced repeated headaches with the beginning of HD headache (HDH). In the group of patients with headaches we analyzed characteristics of headache according to which diagnoses of headaches were made, as well as the effects of HD on headaches. We also analyzed features of HDH. The patients with headache were compared to the patients without haedache regarding sex, age, duration of HD, causes of end-stage renal disease, arterial diastolic and systolic blood pressure and serum concentration of hemoglobin, urea nitrogen, creatinine, sodium and potassium. The results were statistically compared.

RESULTS

In the group of 143 patients examined, 27 (18.9%) patients had headaches. There were no statistically significant differences between the group of patients with headaches and those without headache regarding to sex, age, duration of HD, causes of end-stage renal disease, serum concentration of hemoglobin, urea nitrogen, creatinine, sodium and potassium. The patients with headaches showed significantlly higher mean values of systolic blood pressure during HD in comparison to the patients without headaches (p = 0.029). There was no statistically significant difference between the two groups regarding the mean values of diastolic blood pressure. Nineteen (13.3%) patients had had headache before starting HD. HD did not have any effect on the characteristics of headaches in more than a half of these patients. In 8 (5.6%) patients we diagnozed HDH using the diagnostic criteria of the International Headache Classification of Headache Disorders from 2004. HDH showed similar caracteristics in all the patients: it appeared mostly in men, during the 4th hour of HD, lasted less than four hours, it was localized bilaterally in the frontal parts of the head, strong in intensity, throbbing and without the associated symptoms.

CONCLUSION

The results of our study clearly showed that HDH was a particular entity of headache, not only because of its connenction with HD, but because it had similar characteristics in all the patients in wich it had appeared. Finding out the pathophysiological mechanisms of their occurrence would significantly improve the quality of life style of patients on hemodialysis.

Haemodialysis Fluid: Composition and Clinical Importance

Dialysis fluid is produced by the blending of treated water with electrolytes at the patients bed side. Its preparation and composition are important elements of treatment optimisation since many of the constituents play a role in patient well-being. Ideally the composition of the dialysis fluid should match that of plasma, but due to differences between patients, as well as the increasing number of elderly patients receiving treatment, have resulted in a move towards individualisation of the electrolyte and buffer composition to patient needs. Such individualisation is facilitated by the availability of technology, however it is not yet possible to individualise minor electrolytes, such as K(+), Ca(2+) and Mg(2+). Early dialysis treatments were frequently accompanied by pyrogen reactions arising from bacterial contamination of the dialysis fluid. Today the focus is on the stimulation of mononuclear cells by bacterial fragments contributing to chronic inflammation associated with long-term haemodialysis therapy, and which has led to suggestions regarding the desirability of using ultra-pure dialysis fluid to prevent or to delay complications associated with their presence.