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Headache (Acute - Adult)

Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Headache (October 2008)

Complete Clinical Policy on Acute Headache (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs).

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with acute, nontraumatic headache.

Exclusion Criteria. This guideline is not intended to address the care of pediatric patients or the care of patients with trauma-related headaches.

Critical Questions

1. Does a response to therapy predict the etiology of an acute headache?

  • Level A recommendations. None specified.

  • Level B recommendations. None specified.

  • Level C recommendations. Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.


2. Which patients with headache require neuroimaging in the ED?

  1. Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (eg, focal deficit, altered mental status, altered cognitive function) should undergo emergent* noncontrast head CT.

  2. Patients presenting with new sudden-onset severe headache should undergo an emergent* head CT.

  3. HIV-positive patients with a new type of headache should be considered for an emergent* neuroimaging study.

* Emergent studies are those essential for a timely decision regarding potentially life-threatening or severely disabling entities.

  • Level C recommendations. Patients who are older than 50 years and presenting with new type of headache but with a normal neurologic examination should be considered for an urgent† neuroimaging study.
    †Urgent studies are those that are arranged prior to discharge from the ED (scan appointment is included in the disposition) or performed prior to disposition when follow-up cannot be assured.


3. Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain CT scans are interpreted as normal?

  • Level A recommendations. None specified.

  • Level B recommendations. In patients presenting to the ED with sudden-onset, severe headache and a negative noncontrast head CT scan result, lumbar puncture should be performed to rule out subarachnoid hemorrhage.

  • Level C recommendations. None specified

4. In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study?

  1. Adult patients with headache and exhibiting signs of increased intracranial pressure (eg, papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture.

  2. In the absence of clinical findings suggestive of increased intracranial pressure, a lumbar puncture can be performed without obtaining a neuroimaging study. (Note: A lumbar puncture does not assess for all causes of a sudden severe headache.)


5. Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture?

  • Level A recommendations. None specified.

  • Level B recommendations.  Patients with a sudden-onset, severe headache who have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended.

  • Level C recommendations. None specified.


Purpose of ACEP’s Clinical Policies

Clinical Findings and Strength of Recommendations