Middle meningeal artery infusion for headaches after aneurysmal subarachnoid hemorrhage: a pilot study.

Introduction: Headache is a common and disabling symptom after aneurysmal subarachnoid hemorrhage (aSAH), often requiring high-dose opioids. Meningeal inflammation and dural nociceptor activation may contribute. The middle meningeal artery (MMA), which supplies the dura, offers a route for targeted therapy.

Objective: To evaluate whether dural infusion of lidocaine±dexamethasone during aneurysm embolization reduces pain and opioid use.

Methods: Between February and June 2025, nine patients with aSAH (Hunt and Hess grade 1-2 with Visual Analog Scale (VAS) score ≥7 were prospectively assigned to: (1) lidocaine+dexamethasone (L+D, n=3), (2) lidocaine only (L, n=3), or (3) no infusion (Control, n=3). MMA infusion was performed during embolization using a standard microcatheter technique. VAS was recorded at baseline, immediately postoperatively, 4-24 hours, 7 days, and 1 month. Primary outcomes were pain reduction and opioid use (oral morphine equivalents, OME). Statistical comparisons used non-parametric tests.

Results: Postoperative median VAS fell from 7.0 to 6.0 in Controls (14%), 8.0 to 2.0 in L+D (75%), 8.0 to 4.0 in L (50%) (pooled P=0.016). First-day pain burden: 31 (Control), 9 (L+D), 21 (L), 15 (pooled; P=0.012). Early subacute burden: 9 (Control), 5 (L+D), 7 (L), 6 (pooled; P=0.024). Late subacute: 6 (Control), 3 (L+D), 5 (L), 4 (pooled; P=0.029). Cumulative burden: 42 (Control), 16 (L+D), 30 (L), 23 (pooled; P=0.012). Median OME: 16.7 mg (Control), 5.6 mg (L+D), 0 mg (L), 2.8 mg (pooled). There were no complications.

Conclusion: MMA infusion appears safe and may provide sustained, opioid-sparing pain relief after aSAH. Larger studies are needed to confirm efficacy and to optimize protocols.