HEADACHE BEFORE AND AFTER OPERATION IN GYNAECOLOGICAL PATIENTS

Brit. J. Anaesth. (1969), 41, 401

HEADACHE BEFORE AND AFTER OPERATION IN GYNAECOLOGICAL PATIENTS BY J. G. HANNINGTON-KIFF SUMMARY

Little has been published concerning the incidence of headache in relation to general anaesthesia. This may be because such headache is rare or undetected by the anaesthetist. If detected it may be considered of minor consequence: for instance, headache is listed as a "minor sequel of anaesthesia" by Edmonds-Seal and Eve (1962) and as a "minor postoperative discomfort" by Thomas (1963). The study described here was designed to investigate the incidence and nature of headache in gynaecological patients before and after operation. PATIENTS AND METHOD

Eighty-three patients admitted for gynaecological operations were questioned about headache before and after operation. All patients on consecutive Friday morning lists were included with the exception of four who were excluded because of language difficulty. The questioning about headache was part of a wider investigation of these patients, and so undue emphasis on headache in this study was avoided. The patients were anaesthetized and interrogated by the author. The patients were questioned about headache: (1) in the anaesthetic room, when they were asked if a headache were present at that moment and if they had noticed a headache when they had first awakened on the day of the operation; and (2) 1-2 hours and again 4-6 hours postoperatively. After a pilot study it was found possible to

divide the patients into two categories according to whether they gave a history of migraine (which was surprisingly common among these patients). In making the diagnosis of migraine the decision was made according to the method described by Whitty, Hockaday and Whitty (1966), in which migraine is affirmed if a patient complains of recurrent stereotyped headache having at least two of the following characteristics: (1) mainly unilateral throbbing headache; (2) visual or other sensory aura; (3) nausea and vomiting; (4) positive family history; (5) cyclical vomiting in childhood. On the basis of their management the patients were divided into three groups: (1) "Unpremedicated minor cases", mainly cervical procedures, who were treated as day cases. In this group there were 24 patients, of whom half gave a history of migraine. (2) "Premedicated minor cases", also mainly cervical procedures, who had been admitted on the previous day and kept in at least one night following the operation. In this group were 23 patients, 10 of whom gave a history of migraine. (3) "Premedicated major cases" admitted for abdominal or vaginal surgery. In this group were 36 patients, of whom 15 gave a history of migraine. Patients admitted as day cases (group 1) were given atropine 0.06 mg/stone (0.009 mg/kg) J.

G.

HANNINGTON-KIFF,

B.SC,

M.B.,

F.F.A.R.C.S.,

Department of Anaesthetics, University of Bristol, Bristol, England.

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The incidence and nature of headache before and after operation were investigated in eighty-three of a consecutive series of gynaecological patients. There was a significantly higher incidence of pre-operative and postoperative headache in unpremedicated minor cases than in premedicated minor and major cases. It was found that the incidence of both pre-operative and postoperative headache was higher in those cases who had given a history of migraine. Factors which may have played a part in the development of headaches in these patients are discussed.

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402

RESULTS

For convenience, unpremedicated day cases will be referred to simply as "day cases" and premedicated minor cases as "minor cases" and premedicated major cases as "major cases". Headache in the pre-operative period. Table I shows the number of patients who developed headache on awakening on the day of operation and/or at the time of induction of anaesthesia. The minor and major cases were managed identically in the pre-operative period and there is no significant difference in the incid-

ence of pre-operative headache in these two groups (P=0.29). However, there is a significantly higher incidence of pre-operative headache in day cases compared with the minor and major cases added together (P=0.008). TABLE I

Incidence of patients with headache before operation.

Patients with headache Patients with no headache

Day cases 8 16

Minor cases

Major cases

3 20

2 34

24

23

36

Total patients Groups compared Minor and major Day and minor + major

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intravenously at the time of induction with thiopentone. Patients who were to undergo minor or major surgery were given pethidine 7.5 mg/stone (1.2 mg/kg) and atropine 0.06 mg/stone (0.009 mg/kg) 1 hour before operation. General anaesthesia was induced in both groups for minor surgery with intravenous thiopentone 25-30 mg/ stone (3.9—4.7 mg/kg) and maintained with nitrous oxide and oxygen (the latter in excess of 30 per cent) supplemented by halothane 1.5-2.0 per cent, in a Magill circuit. The duration of each minor operation was 15-20 minutes. Patients for major surgery received a premedication of pethidine and atropine 1 hour before operation in the same dosage as that described for minor surgery, and anaesthesia was induced with intravenous thiopentone 20-25 mg/stone (3.13.9 mg/kg). A cuffed endotracheal tube was passed after intravenous injection of suxamethonium 5 mg/stone (0.8 mg/kg). Anaesthesia was maintained with nitrous oxide, oxygen (in excess of 30 per cent) and halothane 0.5 per cent; muscle relaxation was continued with gallamine 12 mg/ stone (1.9 mg/kg). A circle system was used with carbon dioxide absorption and the vaporizer was outside this system. Ventilation was performed by hand with a minute volume of about 8-10 l./min, as measured by a Wright meter in the expiratory limb of the circuit. Reversal of the effects of the muscle relaxant was accomplished using intravenous injection of neostigmine 0.25 mg/stone (0.04 mg/kg) 3 minutes after intravenous injection of atropine 0.12 mg/stone (0.02 mg/kg). The operation time for most major cases was about 1 hour. The results were analysed statistically, using the method for exact probability of a 2 x 2 contingency described by Fisher (1958).

Statistical analysis P=0.293; not significant P=0.008; significant

Table II shows that in each of the three groups, patients with a history of migraine suffered a higher incidence of pre-operative headache than those with no history, but only in the day cases was this difference statistically significant (P = 0.014). Table II also shows that only 1 of 46 patients with no history of migraine developed a headache pre-operatively; therefore, attention will be paid only to the migraine categories for the rest of the discussion of pre-operative headache. TABLE II

Incidence of pre-operative headache in each group divided according to whether there is a history of migraine. ]Patients

Patients with with no Total headache headache patients Day cases with migraine 7 5 12 Day cases with no 1 11 12 migraine Minor cases with migraine 3 7 10 Minor cases with no 0 13 13 migraine Major cases with migraine 2 13 15 Major cases with no 0 21 21 migraine Groups compared Statistical analysis Day, migraine and no P=0.014; significant migraine Minor, migraine and no P=0.068; not significant migraine Major, migraine and no P=0.167; not significant migraine

Tables III and IV illustrate the way in which, during the course of the morning, the unpremedicated day cases developed a significantly

403

HEADACHE BEFORE AND AFTER GYNAECOLOGICAL OPERATION higher incidence of headache. Table III shows that in the early period just after awakening the three groups showed no significant difference in the incidence of headache; however, in the anaesthetic room the incidence of headache in the unpremedicated day cases has become significantly higher than in the premedicated minor or major cases (table IV). TABLE III

Incidence of headache just after awakening in patients with a history of migraine.

i

Groups compared Day and minor Day and major Minor and major

Minor cases

Major cases

3 7

2 13

12

10

15

Statistical analysis P =0.406; not significant P=0.611; not significant P=0.301; not significant

Total patients Groups compared Day and minor Day and major Minor and major

12

10

Table V shows how the changes in incidence of headache occurred during the course of the morning in the three groups. None of the patients in the minor or major groups, all of whom had received a premedication, had a headache in the anaesthetic room, and the 3 patients who had noticed headache early on awakening stated that premedication had cured them. It would appear

TABLE V

Chart showing pattern of headache in patients before and after operation. Total patients in each group

No. of patients with headache

Pre-operative headache Early

(1) Patients with history of migraine. 12 day cases 10

Late

Postoperative headache 1-2 hr

4-6 hr

Observations Patient pressing temple Patient pressing temple Scotoma postoperatively Patient pressing temple Patient pressing temple Ptosis, swelling of face Teichopsia postop.

10 minor cases

Early premedication Pethidine 3 hr postop.

15 major cases

Teichopsia pre-op. (2) Patients with no history of migraine. 12 day cases 3 —

13 minor cases 21 major cases

15

Statistical analysis P=0.0046; significant P=0.0009; significant No headaches in either group Downloaded from http://bja.oxfordjournals.org/ at University of Manchester on May 11, 2015

Patients with headache Patients with no headache Total patients

Day cases 2 10

TABLE IV

Incidence of headache present in anaesthetic room m patients with a history of migraine. Minor Major Day cases cases cases 0 0 7 Patients with headache 15 10 5 Patients with no headache

No minor or major cases without a history of migraine developed a headache Key: + + severe headache; + mild headache; — no headache.

404 that some form of sedation after admission in the day cases might have been beneficial, for it was after admission that the significant increase in the incidence of headaches had arisen.

TABLE VI

The incidence of postoperative headache in patients with no history of migraine. Day cases Patients with headache Patients with no headache Total patients Groups compared Day and minor Day and major Minor and major

Minor cases

Major cases

3

0

0

9

13

21

12 13 21 Statistical analysis P=0.096; not significant P=0.040; significant No headaches in either group

TABLE VII

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Headache in the first 6 hours after operation. Table VI shows that no postoperative headache was reported in the minor and major cases without a history of migraine. However, 3 day cases with no history of migraine did report postoperative headaches. There is no significant difference in the incidence of postoperative headache in the day and minor cases without a history of migraine (P = 0.096). There is a significant difference between the day and major cases with no history of migraine (P = 0.040), but some of the major cases received pethidine postoperatively and so the circumstances were different. Table VII shows that in patients with a history of migraine there is a significantly higher incidence of postoperative headache in the day cases than in both the minor cases (P = 0.003) and the major cases (P=0.0003). Table VIII shows that 7 day cases developed headache of the 8 who had a pre-operative headache, whereas the proportion for those with no pre-operative headache was 5 of 16. The higher incidence of postoperative headache in day cases with pre-operative headache than in those without pre-operative headache is statistically significant. (P=0.0082.) The corresponding figures for the patients in the premedicated minor group gave no such significant difference. Table V shows that the only patients to have suffered severe postoperative headaches were day cases with a history of migraine. Four of these patients were pressing on the superficial temporal artery on the side of the headache, which manoeuvre some migraine sufferers find effective in reducing the intensity of the throbbing headache and one of these patients was seen to have ptosis and swelling of the face on the same side. One of the day cases with a history of migraine, who had reported a mild pre-operative headache, had no postoperative headache but described a black area in her field of vision (negative scotoma) at the first postoperative visit. This defect had disappeared before the second postoperative visit. Evidently those day cases with a history of migraine were suffering attacks of migraine post-

BRITISH JOURNAL OF ANAESTHESIA

Incidence of headache in the first 6 hours after operation in patients with a history of migraine. Day cases

Minor cases

Patients with headache

Major cases 1 14

Patients with no headache Total patients

12

10

15

Statistical analysis P=0.0035; significant P=0.0003; significant P=0.400; not significant

Groups compared Day and minor Day and major Minor and major

TABLE VIII

Relationship of headache before and after operation in unpremedicated day cases and premedicated minor cases.

PostNo postoperative operative headache headache Totals Day cases Pre-operative headache No pre-operative headache Minor cases Pre-operative headache No pre-operative headache

7

1

8

5

11

16

1

2

3

0

20

20

Groups compared for incidence of postoperative headache. Day cases: Pre-operative headache and no pre-operative headache (statistical analysis: P=0.0082; significant). Minor cases: Pre-operative headache and no pre-operative headache (statistical analysis: P=0.130; not significant).

HEADACHE BEFORE AND AFTER GYNAECOLOGICAL OPERATION

lished series of gynaecological patients admitted as day cases, that two such patients with a history of migraine developed severe pounding headaches shortly after being given intramuscular atropine as premedication. Missing a meal can cause headache in patients with a history of migraine (Critchley and Ferguson, 1933; Blau and Cumings, 1966; Blau et al., 1967) and so routine pre-operative starvation in itself may well contribute to the development of headache in these cases. It is interesting that several of the patients who developed preoperative headache in this study expressed the opinion that if they had been allowed a cup of tea earlier in the morning, this would have prevented their headaches.

DISCUSSION

Thomas (1963) reported that headache was the commonest postoperative complaint in patients anaesthetized for minor gynaecological procedures. The anaesthetic management of his cases was comparable to that of the pre-medicated minor cases described here, and he found postoperative headache to be present in 15 out of 100 patients, whereas the corresponding figures obtained here were 1 out of 23 cases. However, in the present study a high incidence of postoperative headache was found in unpremedicated "day" cases (12 out of 24 cases); furthermore, such headaches occurred particularly in those patients with a history of migraine, the definition of which has been quoted. A study is necessary to establish whether patients admitted as day cases, particularly those with a history of headaches, can be better managed by the administration of a sedative or mild analgesic when first admitted to the ward on the day of operation. Tyrrell and Feldman (1968) reported that in dental cases premedicated only with atropine there was a higher incidence of postoperative headache in patients who had received halothane than in those who had not. The present study has shown that any investigation of the factors which can contribute to postoperative headache must take into account whether headache was present in the pre-operative period in unpremedicated cases. Wolff (1963) has reported the onset of severe headache in a patient subject to migraine following the parenteral administration of atropine and it was noted by the present author, in an unpub-

ACKNOWLEDGEMENTS

I am grateful to Professor H. G. Dixon for permission to publish details of these patients who were in his care. I am particularly indebted to Miss E. H. L. Duncan for advice in the statistical analysis and for the use of a computer programme to make the calculations. REFERENCES

Blau, J. N., and Cumings, J. N. (1966). Method of precipitating and preventing some migraine attacks. Brit. med. J., 2, 1242. Horsfield, D., Quick, J., and Cumings, J. N. (1967). Background to Migraine, 1st ed., p. 146. London: Heinemann. Critchley, M., and Ferguson, F. R. (1933). Migraine. Lancet, 1, 123. Edmonds-Seal, J., and Eve, N. H. (1962). Minor sequelae of anaesthesia: pilot study. Brit. J. Anaesth., 34, 44. Fisher, R. A. (1958). Statistical Methods for Research Workers, 13th ed. Edinburgh: Oliver and Boyd. Thomas, E. (1963). Pre- and postoperative minor discomforts. Brit. J. Anaesth., 35, 327. Tyrrell, M. F., and Feldman, S. A. (1968). Headache following halothane anaesthesia. Brit. J. Anaesth., 40, 99. Whitty, C. W. M., Hockaday, J. M., and Whitty, M. M. (1966). The effect of oral contraceptives on migraine. Lancet, 1, 856. Wolff, H. G. (1963). Headache and other Head Pain, 2nd ed., p. 302. New York: Oxford University Ptess. CEPHALEES PRE- ET POSTOPERATOIRES CHEZ DES PATIENTES GYNECOLOGIQUES SOMMAIRE

La frequence et la nature des maux de tete, avant et apres une operation, ont ete etudiees dans une se'rie de 83 interventions gynecologiquss consecutives. La frequence des cephalees pre- et postoperatoires etait significativement plus elevee dans les cas mineurs sans premedication, que dans les cas mineurs et majeurs avec premedication. On a observe une frequence plus

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operatively. Four out of the 7 day cases who reported severe postoperative headache still had severe headache when they were due to leave hospital. The only premedicated minor case to suffer from postoperative headache had given a history of migraine and had been given her premedication more than 2 hours pre-operatively because of delay in the theatre and she had begun to feel anxious by the time she arrived in the anaesthetic room. Another minor case with a history of migraine had no postoperative headache but reported teichopsia postoperatively: she had noticed a mild headache when she had awakened on the day of operation but this had been cured by the premedication.

405

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406 elevee des cephalees, aussi bien pre- que postoperatoires, chez les patientes avec une anamnese de migraine. L'auteur discute les facteurs qui auraient pu jouer un role dans le developpement des maux de tete chez ces patientes. KOPFSCHMERZEN VOR UND NACH DER OPERATION BEI GYNAKOLOGISCHEN PATIENTINNEN ZUSAMMENFASSUNG

Haufigkeit und Natur von vor und nach der Operation auftretenden Kopfschmerzen wurden bei 83 nicht

ausgewahlten, gynakologischen Patientinnen untersucht. Bei nicht vorbehandelten Patientinnen, die sich kleineren operativen Eingriffen zu unterziehen hatten, wurde bedeutend haufiger iiber pra- und postoperativ auftretende Kopfschmerzen geklagt als bei Patientinnen, die eine Pramedikation erhalten hatten, gleichgiiltig ob bei ihnen ein kleiner Eingriff oder eine schwere Operation folgte. Ferner wurde festgestellt, dafi Patientinnen mit einer Migrane-Anamnese haufiger unter Kopfschmerzen vor und nach der Operation litten als andere Patientinnen. Faktoren, die bei der Entwicklung der Kopfschmerzen dieser Patientinnen eine Rolle gespielt haben konnten, wurden diskutiert.

Sleep and Altered States of Consciousness (Res. Publ. Nervous Mental Diseases Vol. XLV). Published by Williams & Wilkins Co., Baltimore, 1967. Pp. 591; 211 illustrations; 25 tables. This book constitutes the published proceedings of a Symposium held on December 3 and 4, 1965. Most of the papers can be considered as relating to one of three subjects: (1) the internal clock; (2) rapid eye movement (r.e.m.) sleep; and (3) effect of sleep deprivation. The internal clock is of value to animals in controlling their autonomic and behavioural function, e.g. ;t ensures that nocturnal predators emerge from their burrows at the right time and in the best physical condition for hunting. The internal clock probably now serves no function in man but it may still have importance in determining man's behavioural efficiency in relation to the 24-hour clock. Thus subjects with circadian rhythms longer than 24 hours tend to be at their best late at night while those with rhythms shorter than 24 hours are most efficient in the morning; or as one contributor calls them, the "drowsy owls" and the "tiring larks". As pointed out by Dr. L. J. West, these points may have importance in such areas as accident-proneness at work and selection of crew for space flights. Rapid eye movement sleep was first described in 1953 and its discovery has clearly caused an explosive reawakening of physiological interest in sleep. Rapid eye movement sleep, which is associated with an e.e.g. pattern of fast activity and low voltage, occurs in bursts of about 20 minutes duration which are separated by periods of slow wave high voltage sleep of 60-80 minutes duration. During r.e.m. phases the following features are present, in addition to the rapid eye movements and fast activity e.e.g.: depression of muscle tone but increased jerky muscle movements; dreaming; increases in blood pressure, pulse, respiratory rate and respiratory arrhythmia; and reductions in arterial oxygen saturation related to the respiratory arrhythmia. This last is thought to be related to nocturnal angina in some patients. Cerebral blood flow and oxygen

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BOOK REVIEW

metabolism are believed to be elevated during r.e.m. sleep. All these features contrast markedly with those of slow wave high voltage sleep during which oxygen uptake, heart rate and blood pressure are all below waking values. In certain psychoses there are alterations in the pattern of sleep. Perhaps the most interesting section of the book, however, to the anaesthetist is that which relates to the effect of sleep deprivation, for this affects him personally and may influence his views on such questions as anaesthetic staffing. Thus Dr. A. Lubin makes the following observations on the effect of acute sleep deprivation on performance: "The subject is unable to maintain efficient behaviour and increasingly shows short periods when performance falters and stops. . . . Between lapses (probably microsleeps) the subject can pull himself together and function at a high level." Work paced tasks are the ones which show greatest deterioration after sleep deprivation and "vigilance tasks such as . . . monitoring communication apparatus for vital information are work paced tasks". These comments are clearly appropriate to the practical question of how safe is it for an anaesthetist to work on elective surgery after sleep deprivation due to acute emergency work. It is likely that many patients having routine surgery would rather have their operations delayed than be in the care of an anaesthetist having microsleeps! Furthermore the opinion of the sleepdeprived anaesthetist is of no help in determining his fitness or otherwise to work, for "subjects often became quite euphoric around the second night of sleep loss, denied that they were sleepy or that their performance was impaired. This very much resembles the behaviour of the pilot suffering from oxygen debt or the diver who experiences nitrogen narcosis". Clearly this book cannot be said to be of close anaesthetic relevance but those who do make time to read it will find it full of interest. Physiological knowledge of sleep has increased enormously in recent years since the first description of r.e.m. sleep and this book provides a readable statement of present understanding and opinion in this field. D. Gordon McDowall