Terlipressin Induced Headache- An Uncommon Phenomenon

Abstract

Introduction: Terlipressin is used in treatment of variceal bleed and hepatorenal syndrome in cirrhotic patients. It may cause neurological or cardiac problems like cardiac ischemia, cerebrovascular ischemia, peripheral ischemia, or mesenteric ischemia. It may also cause confusion, constipation, diarrhea, headache, itching skin, numbness and tingling of the face, fingers, or toes, pain in the arms, legs, or lower back, especially pain in the calves and/or heels upon exertion, pain or discomfort in the arms, jaw, back or neck, pale, bluish-coloured, or cold hands or feet.

Case Report: We report a fifty-two-year-old male, a known case of alcoholic liver disease for last two years who presented with haematemesis and malena for last two days. On clinical examination, he was thin with average stature. He was looking pale with hypotension and reflex tachycardia. He had mild anemia, ascites and bilateral pedal edema. Rest of general physical and systemic examination was normal.  On biochemical evaluation complete hemogram revealed pancytopenia, liver function test was deranged i.e. there was mild hyper bilirubinaemia, transaminitis, hypoproteinaemia and hypoalbunemia. The complete lipid profile was in below normal range but renal function test, serum electrolytes and blood sugar level were in normal range. The ultrasonogram abdomen showed altered echotexture with moderate ascites. The upper gastro-intestinal endoscopy revealed grade two oesophageal varices with stigmata of recent bleed, hence endoscopic variceal ligation was done. The AFP level was normal. His viral screen, autoimmune, wilson’s profile was negative. He was started on injection Terlipressin, vitamin K, broad spectrum antibiotic, proton -pump inhibitor and other supportive therapy. After first dose of injection Terlipressin, he developed severe headache which warranted even need of injectable analgesics. There was no documented hypertension at this point of time, to which headache could have been attributed. Immediately, injection Terlipressin was stopped and patient headache subsided after few hours. After, a gap of one day, again injection Terlipressin was re-started on trial basis but again patient developed severe headache which again needed injectable analgesics. Again, injection Terlipressin was stopped and patient became headache free after few hours. Patient was switched to tablet carvedilol which he tolerated well and he was discharged under haemodynamically stable condition.

Conclusion: Terlipressin is commonly used for treatment of variceal bleed and hepatorenal syndrome. The most common side-effects noted are pain abdomen, diarrhoea, cardiac ischemia but headache is not frequently seen. The awareness regarding the same can lead to timely intervention and substitution with other oral alternative drugs.