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Does this patient have dialysis-induced headache?
Symptoms
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Bifrontal discomfort (throbbing)
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Nausea with or without vomiting
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Aggravated by supine position
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No accompanying visual disturbances
The International Headache Society (IHS) defines dialysis-related headache as a headache with no specific characteristics that develops during hemodialysis and resolves spontaneously within 72 hours of completion of the dialysis session. The following IHS diagnostic criteria are proposed:
A. At least three attacks of acute headache fulfilling criteria C and D
B. Patient is on hemodialysis
C. Evidence of causation demonstrated by at least two of the following:
1. Each headache developing during a hemodialysis session
2. At least one of the following: a) Each headache worsening during the dialysis session b) Each headache resolving within 72 hours after the end of the dialysis session
3. Headache episodes cease altogether after successful kidney transplantation and termination of hemodialysis
D. Not better accounted by another diagnosis according to the International Classification of Headache Disorders, 3rd edition.
Causes
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Caffeine withdrawal (removed during dialysis)
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Acetate dialysate
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Intradialytic hypotension
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Intradialytic hypertension
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Hard water syndrome (high calcium or magnesium in dialysate)
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Fluoride intoxication (contaminated dialysate)
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Chloramine intoxication (contaminated dialysate)
Differential diagnosis
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Dialysis disequilibrium syndrome
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Hypertensive encephalopathy
What tests to perform?
Diagnosis by clinical judgment
Assessment of dialysate for potential chemical contamination if several patients develop headache in the same dialysis unit
How should patients with dialysis-induced headache be managed?
Acute treatment
Oral analgesics (acetaminophen)
Prevention
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Bicarbonate dialysate
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Slow dialysis with reduced blood flow rates
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Sodium profile
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Ultrafiltration profile
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Coffee ingestion during dialysis
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Use of reprocessed dialyzers
What happens to patients with dialysis-induced headache?
Poor quality of life if severe or recurrent
Inadequate dialysis from premature discontinuation of dialysis
Chronic fluid retention from premature discontinuation of dialysis
How to utilize team care?
1. Specialty consultations – Neurologist (in severe form)
2. Nursing – Close monitoring; avoid intradialytic hypotension in high-risk patients
Are there clinical practice guidelines to inform decision making?
Applications – no
Other considerations
ICD-10-CM diagnosis code: G44.1 Vascular headache, not elsewhere classified
ICD-10-CM diagnosis code R51: Headache
What is the evidence?
“Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version)”. Cephalalgia. vol. 33. 2013. pp. 629-808.
Sav, MY, Sav, T, Senocak, E, Sav, NM. “Hemodialysis-related headache”. Hemodial Int. vol. 18. 2014 Oct. pp. 725-9.
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