© Springer-Verlag 2008
Received: 21 May 2008
Accepted: 11 July 2008
Published: 31 July 2008
Headache is a common symptom after cerebral angiography, although it has seldom been studied. We aimed to evaluate the frequency of headache at 24 h and 6 months after angiography and to describe its characteristics. We used a cross-sectional survey of consecutive patients submitted to angiography and determined headache presence and its characterization. Headache occurrence was analyzed against headache history, clinical data, technical and demographical variables. Of 107 procedures studied, 51.3% patients experienced headaches within 24 h. Patients more likely to experience headaches were females or had subarachnoid hemorrhage. Six months post-procedure 48.8% of patients had frequent headaches. These patients had a positive headache history before the procedure, migraine in particular. Half of patients undergoing routine angiography experience benign post-procedure headaches within 24 h (especially women), yet it does not seem to predispose to chronic long-term headaches.
The safety of cerebral angiography has greatly evolved since its development by Moniz , yet the prevalence of neurological complications is still 2.3% . Estimated headache incidence after cerebral angiography is 0.3%  although a 43% prevalence of migraine headache after angiography was described in migraine patients .
One study  designed to identify post-angiography headache used a small sample of cerebrovascular patients and reported 33% incidence of post-angiography headache. The International Classification of Headache Disorders  does not recognize post-angiography headache, only headaches starting during angiography or within 24 h of embolization.
We aimed to study post-procedure headaches, in order to (1) establish its frequency, (2) identify predisposing factors to its occurrence and to (3) determine its relation to previous headaches.
A prospective cross-sectional observational study was conducted on consecutive adult patients undergoing digital subtraction angiography (DSA) in a University Hospital; the study protocol was approved by the Hospital’s Ethical Committee. Comatose, confused and non-consenting patients were excluded. Recruitment terminated with the inclusion of the 100th diagnostic DSA.
A semi-standardized interview was applied before the procedure, with demographic, clinical and technical data, screening, characterization and classification  of previous headaches, angiographic findings and/or therapeutic results. One to 5 days after the procedure, an author blinded to previous history applied an identical interview to each patient and registered current clinical status; the same evaluation was made 3–8 months later, by telephone.
SPSS v11.5 was used; frequency analysis performed with non-parametric tests, hypothesis on differences in means between groups tested by independent samples t test. P < 0.05 was considered significant. The relation between post-procedure headaches and the risk factors found significant in bivariate analysis was studied with binary logistic regression; the best fit chosen based on likehood ratio.
A total of 107 patients (67 females, age 52 ± 16.3) and 122 procedures were included; only the first procedure of each patient was analyzed, summing 86 diagnostic DSAs, 19 embolizations and two angioplasties studied. Indications for DSA were subarachnoid hemorrhages (32 patients), stroke (20) and others (unruptured aneurisms, post-therapeutic controls, AVMs, arteriovenous fistulae, tumor). Therapeutic procedures were embolizations of aneurysms (ten), AVMs (three), arteriovenous fistulas (four), tumor rammi (three) and carotid stenosis stenting (one).
Previous history of headache was reported by 47(43.9%) patients; 23 with secondary headaches  and 12 migraine. Female gender was related to the presence of previous headaches (P = 0.005).
Seventy-eight (72.9%) patients were available for revaluation occurring on an average 28 ± 15h 54 min after the procedure (mode 24 h); lost patients were early discharged (12) or had impaired communication (ETE, aphasia, coma, confusion). Forty (51.3%) patients reported headaches since the procedure—17 continuous pain, 12 a single headache episode and 11 several episodes (average 4.4 ± 5.5). A headache-free interval between the procedure and pain onset occurred in 31 patients, lasting 10.4 ± 7.6 h. Headache was a mild (59%) stabbing (45%) bilateral (55%) pain referred to the trigeminal territory (66.7%). Most cases were without photophobia (61.5%), phonophobia (56.4%), nausea or vomiting (84.6%). Headache was classified as migraine in three patients (one with previous migraine), tension-type headache (nine) and secondary in 28 patients.
Female gender (P = 0.013, RR 2.50, 95% CI 1.34–4.68) and diagnosis of aneurysm or SAH (P = 0.022, RR 2.16, 95% CI 1.41–3.33) were risk factors for post-procedure headaches. Separate group analysis of SAH patients (N = 30) identified younger age (55.3 vs. 68.9, P = 0.034) and lower average contrast dye iodine concentration (327.6 vs. 357.1, P = 0.033) to relate to headache occurrence in these patients. In patients without SAH (N = 48) only female gender (P = 0.005) presented as a risk factor, yet sample was too small to calculate relative risk.
A telephonic evaluation performed 164 ± 61.6 days post-procedure included 82 patients (63.4% females, age 51.3 ± 16.8); patients lost to follow-up were due to impossibility of telephonic contact and death (one). Forty patients (48.8%) described recurrent headaches since the procedure, 12 of which related its onset to the procedure. Seven patients had less than a total of four attacks; the remaining had 20.7 ± 33.6 episodes monthly, ranging from one every 2 months to five daily attacks. The episodes lasted less than 12 h in 75% patients, average duration 2.7 ± 5.2 h. Six patients had daily persistent headaches.
Headaches after angiography are common, yet information about them is insufficient—its “benign” character is probably the reason why prospective series evaluating DSA complications fail to screen for headache .
We report 35.4% incidence of headaches 24 h after angiography (excluding SAH patients) in agreement with published data . We could not identify “typical” post-procedure headache characteristics, probably reflecting its multifactorial etiology. Female gender was the only risk factor for post-procedure headache occurrence—a higher prevalence of most headache types on females has been documented in epidemiological studies  probably due to hormonal or pain perception threshold issues [7–9]. In opposition previous data , we did not find a relation neither with previous headaches nor migraine. Post-procedure headache onset had a delay of hours after the procedure—a fact previously reported [4, 5, 10] that has been attributed to a triggering effect of cerebral angiography in susceptible individuals . In our series, post-procedure migraine was rare (three patients).
Case reports of post-angiography migraine [10–12] after DSA or embolizations for cerebrovascular disease , vascular malformations and cortical dysplasia [10, 12] were described. In four cases, intra-angiographic onset of vasospasm in the posterior brain regions occurred, then typical aura developed with subsequent headache ; one case had vasodilatation of the fronto-temporal meningeal vessels 24 h after the onset of a migraine-like headache without aura . It is possible that direct or indirect arterial stimulation induces the cortical spreading depression phenomena and consequent migraine-like headache, sometimes preceded by focal neurological symptoms localizing blood flow changes . As with our series, some of these patients did not have previous migraine.
To our knowledge, this is the first study on late recurrent post-procedure headaches. Data suggests a relation to previous headaches (migraine in particular) so probably it is just a reflection of its recurrent pattern. Patients often relate the onset/aggravation of complaints to procedures; in our series, 19.6% of patients without previous headaches described new-onset headaches since the procedure, representing 22.5% of patients with recurrent headaches 6 months post-procedure. The explanation maybe a higher valorization of headache complains after an invasive intervention, also conditioned from increased self awareness and learning that headache can be a warning sign of intracranial pathology.
In conclusion, early post-angiography headache is common and must be foreseen, especially in women; it tends to be a mild headache starting a few hours after the procedure; so, a simple analgesic scheme prescribed si opus sit can promote comfort. Migraine is rarely triggered by cerebral endovascular procedures. Angiography does not seem to influence the occurrence of chronic recurrent headaches; causality remains to be determined in the minority of patients whose chronic headaches develop after angiography.
Conflict of interest
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