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Headache

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

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

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

    Recommendations
    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.

    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.

  • Which patients with headache require neuroimaging in the ED?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    (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.

    Level A Recommendations

    None specified.

    Level B Recommendations

    (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.

  • 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?

    Recommendations
    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.

    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.

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

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (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.)
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (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.)
  • 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?

    Recommendations
    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.

    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.

Download the Policy

PDF Icon CPHeadache.pdf.pdf April 2018

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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