Written by Vivian Lei
This ACEP clinical policy presents evidence-based recommendations on the management of patients presenting to the ED with acute headache.
Why does this matter?
Headaches are a common complaint in the ED, and etiologies can range from potentially life-threatening to benign. This clinical policy presents answers to several key questions in the evaluation and management of adult patients with acute headache. Recommendations are graded as follows:
Level A – generally accepted patient care principles based on high quality evidence
Level B – recommendations based on moderate quality evidence
Level C – recommendations based on lower quality evidence or consensus recommendations because no good data exists
These were the questions they addressed:
1. In the adult ED patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?
The Ottawa Subarachnoid Hemorrhage Rule is the only risk stratification tool that has been validated and identifies the need for neuroimaging in acute headache. It has a high sensitivity but lacks specificity for SAH.
Patients with a normal neurologic examination and peak headache intensity within 1 hour of pain onset require investigation if one or more of the following is present:
Symptoms of neck pain or stiffness
Age ≥40 years old
Witnessed loss of consciousness
Onset during exertion
Thunderclap headache (peak intensity immediately)
Limited neck flexion on exam
Level B recommendation
2. In the adult ED patient treated for acute primary headache, are nonopioids preferred to opioid medications?
Nonopioid medications are strongly preferred for treatment of acute primary headaches in the ED patients.
Level A recommendation
3. In the adult ED patient presenting with acute headache, does a normal noncontrast head CT scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for SAH?
A normal noncontrast head CT performed within 6 hours of symptom onset in an ED headache patient with a normal neurologic exam can be used to rule out a nontraumatic SAH without performing an LP.
Level B recommendation
4. In the adult ED patient who is still considered to be at risk for SAH after a negative noncontrast head CT, is CTA of the head as effective as LP to safely rule out SAH?
In patients considered to be at risk for SAH after negative noncontrast head CT, CTA is a reasonable alternative to LP for safely ruling out SAH. ACEP recommends using shared decision making to select the best diagnostic test with regard to pros and cons of CT/LP versus CT/CTA.
Lumbar puncture is a time-intensive procedure with a low diagnostic yield, a high rate of traumatic taps, high rate of uninterpretable test results, and a risk of post-LP headache.
CTA avoids many of the negative aspects of performing an LP. However, it may identify incidental cerebral aneurysms leading to unnecessary invasive procedures, is associated with a higher radiation dose, and risks missing an alternative diagnosis through LP.
Level C recommendation
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache: Approved by the ACEP Board of Directors June 26, 2019 Clinical Policy Endorsed by the Emergency Nurses Association (July 31, 2019). Ann Emerg Med. 2019 Oct;74(4):e41-e74. doi: 10.1016/j.annemergmed.2019.07.009.
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Reviewed by Clay Smith