Pain Control and Anxiolysis After Subarachnoid Hemorrhage Using Immersive Virtual Reality: A Case Report

Abstract

Debilitating headache persists after acute aneurysmal subarachnoid hemorrhage (SAH). Despite high prevalence, little is known regarding optimal treatment strategies for SAH-related headache. Nonpharmacologic adjunctive therapies are emerging as tools to help treat pain and limit opioid exposure in the hospital. Virtual reality (VR) is an immersive audiovisual experience that has been shown to reduce pain perception in other patient populations. The role of VR in acute brain injury is unknown. Here we report a patient with SAH who suffered from persistent headache during her hospitalization despite escalation of analgesic pharmacotherapy. A trial of VR was used as an adjunct to medication over four days. The patient reported subjective improvement in pain and anxiety. VR may provide additional analgesia and anxiolysis over pharmacologic measures alone and warrants further study in patients with acute brain injury.

Introduction

Aneurysmal subarachnoid hemorrhage (SAH) nearly always presents with headache. The pain is often severe and persistent throughout the hospitalization. ¹ Headache is a common reason for readmission following SAH, and many patients continue to suffer for years following aneurysmal rupture.^2,3 Opioids remain the backbone of pharmacotherapy and may contribute to unacceptably high rates of post-SAH chronic opioid use. ⁴

Multimodal analgesic strategies are used for other conditions in the intensive care unit in order to limit opioid usage and avoid opioid dependence. ⁵ More recently, interest has surged in the utilization of nonpharmacological adjuncts to pain management. Virtual reality (VR) is an immersive technology using a head-mounted display with audio to provide an interactive virtual environment. While first employed in patients with severe burn injuries, VR has shown promise in a variety of other acute and chronic pain conditions, including chronic headache.^6-8 To date, however, there has been no investigation into the role of VR to treat pain following SAH.

We describe the case of a patient with SAH who utilized VR as an adjunct to pharmacologic measures to control persistent headache pain and anxiety.

Case Presentation

A 45-year-old woman presented with severe headache, neck pain, and nausea. She had a history of migraine headaches with no prior treatment. She did not have a history of depression or motion sickness.On admission, she was found to have a modified Fisher 3 SAH without hydrocephalus due to a 4 x 5 mm anterior communicating artery aneurysm that was endovascularly coiled. Due to residual aneurysm filling at the neck, she was informed that she would need a craniotomy for clipping of the aneurysm, which was deferred to the post-acute setting.

She reported severe, persistent headache refractory to oral acetaminophen and oxycodone and significant anxiety regarding future aneurysm clipping. Adjunctive gabapentin was initiated and increased to 900 mg three times daily without relief. She underwent two short courses (∼48 hours) of dexamethasone (4 mg every six hours) for refractory headache. Integrative care provided support through acupressure, music and massage therapy which provided some anxiolysis.

On post-bleed day eight she began the first of four daily VR sessions with the Oculus Rift (Oculus VR, Irvine, CA, Figure 1A). Medical pain management continued as reported above. Each session lasted approximately 30 minutes. Programs used during the session included a fast-paced game (Fruit Ninja, Halfbrick Studios, Brisbane, Australia), an interactive environment with eight minigames/virtual experiences (The Lab, Valve Corporation, Bellevue, WA), a guided meditation (Guided Meditation VR, Cubicle Ninjas, Chicago, Ill.), and an immersive movie (Crow: The Legend, Baobab Studios Inc., Redwood City, CA.).

Figure 1.

(A) Photograph of patient using virtual reality setup in hospital bed. Permission granted by patient. (B) Daily maximum numerical rating score (range 1-10) over the patient’s hospital course (PBD, post bleed day). Black bar represents days that VR was utilized by the patient.

After each session, the patient reported a decrease in both pain and anxiety (Table 1). Her vital signs including heart rate and blood pressure were stable pre- and post-VR therapy. Overall, her pain scores improved during VR therapy. The improvements lasted several days after the last VR session before rebounding to pre-VR levels (Figure 1B). She had never used VR recreationally in the past. When asked if she enjoyed the experience and if she would use VR again, she answered, “yes” after each VR session. She specifically liked “the interactivity” and “pain relief” during the sessions. She reported “exhaustion” following the second and fourth VR sessions. She did not experience any other side-effects of the treatment such as light sensitivity, motion sickness or claustrophobia. Written consent for a clinical trial and case report was obtained from patient prior to starting VR sessions.

Table 1.

Assessment of pain and anxiety, pre- and post-treatment.

	DAY 1		DAY 2		DAY 3		DAY 4
	PRE	POST	PRE	POST	PRE	POST	PRE	POST
Pain
Are you experiencing pain?	Tolerable	No pain	Moderate	No pain	Tolerable	No pain	Tolerable	No pain
Anxiety
Feeling nauseous, anxious or on edge?	Mild	Not at all	Mild	Not at all	Not at all	Not at all	Mild	Mild
Not being able to sleep or control worrying?	Mild	Not at all	Not at all	Not at all	Mild	Not at all	Not at all d	Not at all
Worrying about illness?	Mild	Not at all	Not at all	Not at all	Mild	Not at all	Mild	Mild
Trouble relaxing?	Moderate	Not at all	Moderate	Not at all	Moderate	Not at all	Not at all	Not at all
Become easily annoyed or irritable?	Moderate	Not at all	Moderate	Not at all	Mild	Mild	Mild	Not at all
Feeling afraid as if something awful may happen?	Not at all	Not at all	Mild	Not at all	Not at all	Not at all	Not at all	Not at all

Discussion

Persistent, debilitating headache is common following SAH. Current guidelines recommend opioids for analgesia, ⁹ but their use may worsen pain and contribute to chronic opioid use disorder by inducing nociceptive sensitization. ¹⁰ A multimodality approach is likely required to improve pain-related outcomes following SAH.

Non-opioid pain management is limited in headache due to SAH. Non-steroidal anti-inflammatory drugs increase the risks of bleeding, acute kidney injury, and gastrointestinal ulcers. Gabapentin and pregabalin can be sedating and, similar to opioids, may become drugs of abuse or dependence. Corticosteroids increase medical and psychiatric complications. ¹¹ Nonpharmacologic therapies may reduce pain and opioid dosage in the setting of acute brain injury with minimal adverse effects. Recently, acupuncture therapy was shown to reduce pain scores and analgesic use in a small series of patients with persistent headache following nontraumatic SAH. ¹²

The mechanism of hypoalgesia in VR remains uncertain. VR diverts attention from painful stimuli to a virtual environment, reducing perception of incoming nociceptive signals. Additional mechanisms include an increase in vagal activation, reduction of situational anxiety and improvement in mood and affective components of pain. ¹³ In healthy volunteers, VR increases thermal tolerance limits with the use of 3D immersive VR compared to those without 3D immersion. This mechanistic explanation finds support by functional MRI imaging showing reduced activation of sensory and affective pain circuits in those undergoing VR therapy. ¹⁴ Moreover, VR appears to work synergistically with opioids to reduce pain, as participants using VR with systemic opioid analgesia have reported less pain compared to either treatment alone. ¹⁵ Our case suggests VR may have a role in patients with acute brain injury suffering from persistent pain and anxiety.

Whether our findings will generalize to other patients with acute brain injury is unknown. Photophobia and nuchal rigidity may limit the use of VR in patents with SAH. Large, multicenter trials with validated assessments of pain and anxiety are needed to discern the short- and long-term effects of VR. The ideal dose and type of VR session have likewise yet to be established. Our patient engaged in gaming, meditation, and immersive entertainment sessions with equal success, but it is possible that for others the VR session content is as important as the immersive technology itself. For instance, in a study with healthy controls soothing water-based environments were found to increase pain thresholds while an immersive opera experience actually lowered pain thresholds. ¹³ Also unclear is whether desensitization to the pain distraction effects of VR occurs over repeated trials.

Our case highlights the potential for VR as an adjunct therapy to improve pain and anxiety after acute brain injury. Given the promising results from this case study, our institution is prospectively studying patients utilizing identical content on a non-immersive tablet computer and content-free VR as controls to investigate the unique benefit of immersive VR in this patient population. Further studies are needed to explore non-pharmacological adjuncts to pain management in patients with SAH.

ORCID iDs

Adam Kardon https://orcid.org/0000-0001-6595-6722

Mazhar Khalid https://orcid.org/0000-0001-5406-5924