Non-traumatic headache in the emergency department

doi:10.1016/S0196-0644(80)80152-1

Annals of Emergency Medicine

Volume 9, Issue 8, August 1980, Pages 404-409

https://doi.org/10.1016/S0196-0644(80)80152-1 Get rights and content

Four hundred eighty-five patients between the ages of 15 and 89 made 631 visits to a medical center emergency department with a chief complaint of headache or head pain during a 12-month period from May 1977 to April 1978, accounting for 1.6% of all patient visits. One hundred ninety-three (40%) had subsequent follow-up data available for review. Muscle contraction-tension headache and migraine headache were the most common diagnoses, accounting for 54.5% of all patients. The female/male distribution was 3:2 for the entire group. Five percent of the overall group had serious neurological conditions. Analysis of the emergency department evaluations, results of follow-up, and reviews of other recent series are reported. Based on current literature, recommendations for the detailed laboratory evaluation of the suspicious headache are described.

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Cited by (72)

Determining the Diagnostic Utility of Lumbar Punctures in Computed Tomography Negative Suspected Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis
2021, World Neurosurgery
While headache is a common neurologic symptom, subarachnoid hemorrhage (SAH) is a rare and potentially catastrophic cause of sudden-onset severe headache. The utility of the imaging modalities and interventional procedures are central to the investigation of the causes of headache; however, they are not without their limitations, risks, and complications.
A meta-analysis in accordance with the Preferred Reporting for Systematic Reviews and Meta-analysis guidelines was conducted searching PubMed, EMBASE, and Google Scholar. Patients investigated for suspected subarachnoid hemorrhage (SAH) with a negative computed tomography (CT) and positive lumbar puncture (LP) and final diagnosis of SAH were included. The sensitivity of LP in the context of a negative CT and vsubsequent imaging confirming the cause of SAH (computed tomography angiography, magnetic resonance angiography, digital subtraction angiography [DSA]) was quantified. The pooled data were analyzed using the DerSimonian-Laid random effects model.
Four studies with 2782 patients who presented with headache suspicious for SAH were included with an initial negative CT report and a subsequent LP to rule out SAH. All included studies had an observational prospective cohort design. A combined pooled proportion of 0.383 (0.077, 0.756); 0.086 (0.007, 0.238); and 0.22 (0.04, 0.49) for LP+, DSA+, and DSA/computed tomography angiography+ investigations were estimated with a 95% confidence interval.
The current clinical workflow of an LP after a negative CT head for a patient presenting with a sudden-onset severe headache is observed to have a high enough proportion to warrant its continued use despite the sensitivity of modern CT scanners of ≥97%.
Presentation of Headache in the Emergency Department and its Triage
2015, Headache and Migraine Biology and Management
Four million patients present to US emergency departments (EDs) annually with the complaint of headache. The emergency physician must diagnose malignant secondary causes of headache such as aneurysmal subarachnoid hemorrhage expeditiously, treat acute exacerbations of primary headache disorders such as migraine effectively, and provide tailored education to the primary headache patients who use the ED as a medical safety net. The needs of patients who present to EDs are varying and complex – a one-size-fits-all strategy is doomed to failure. Herein, we discuss clinical features of the various secondary headaches that emergency physicians encounter commonly; efficient diagnostic work-ups, including when to order laboratory and imaging tests; and strategies for effective parenteral and post-discharge treatment. The chapter also discusses management strategies for the complicated subgroup of ED patients with comorbid psychiatric illness, medication overuse headache, and opioid dependence who make frequent visits to an ED for management of headache.
Nontraumatic subarachnoid hemorrhage in the setting of negative cranial computed tomography results: External validation of a clinical and imaging prediction rule
2013, Annals of Emergency Medicine
Citation Excerpt :
Approximately 1% to 4% of emergency department (ED) visits for headache are attributable to nontraumatic subarachnoid hemorrhage, with an annual incidence of 1 in 10,000 among the general population.1-5
Clinical variables can reliably exclude a diagnosis of nontraumatic subarachnoid hemorrhage in patients with negative cranial computed tomography (CT) results. We externally validated 2 decision rules with 100% reported sensitivity for a diagnosis of subarachnoid hemorrhage, among patients undergoing lumbar puncture after a negative cranial CT result: (1) clinical rule: presence of any combination of age 40 years and older, neck pain or stiffness, loss of consciousness, or headache onset during exertion; and (2) imaging rule: cranial CT performed within 6 hours of headache onset.
This was a matched case-control study of patients presenting to 21 emergency departments between 2000 and 2011. Patients with a diagnosis of subarachnoid hemorrhage as determined by lumbar puncture after a negative cranial CT result were screened for inclusion. A matched control cohort was selected among patients with a diagnosis of headache after negative cranial CT and lumbar puncture results.
Fifty-five cases of subarachnoid hemorrhage meeting inclusion criteria were identified, 34 (62%) of which were attributed to cerebral aneurysms. External validation of the clinical rule demonstrated a sensitivity of 97.1% (95% confidence interval [CI] 88.6% to 99.7%), a specificity of 22.7% (95% CI 16.6% to 29.8%), and a negative likelihood ratio of 0.13 (95% CI 0.03 to 0.61) for a diagnosis of subarachnoid hemorrhage. External validation of the imaging rule revealed that 11 of 55 subarachnoid hemorrhage cases (20%) had negative cranial CT results for tests performed within 6 hours of headache onset.
The clinical rule demonstrated useful Bayesian test characteristics when retrospectively validated against this patient cohort. The imaging rule, however, failed to identify 20% of subarachnoid hemorrhage patients with a negative cranial CT result.
Acute Headache
2011, Pain Management, Second Edition
Acute headache in the emergency department
2010, Handbook of Clinical Neurology
Citation Excerpt :
Headache is an extremely common complaint in the emergency department, accounting for 1–16% of all visits according to studies (Dhopesh et al., 1979; Dickman and Masten, 1979; Leicht, 1980; Fodden et al., 1989; Silberstein, 1992; Luda et al., 1995; Ramirez-Lassepas et al., 1997; Morgenstern et al., 1998; Newman and Lipton, 1998; Stevenson et al., 1998; Cortelli et al., 2004).
In the acute setting, the primary objective is to decide whether the headache is primary, secondary but benign (for example a headache associated with a cold), or secondary to a potentially life-threatening cause (subarachnoid hemorrhage (SAH), bacterial meningitis, intracranial hypertension). The cornerstone of headache diagnosis is the interview with the patient, followed by a thorough physical examination. These two first clinical steps determine the need for investigation, immediate with inpatient care or on an outpatient basis, and the treatment to recommend, acutely and for future attacks in the case of primary headache. The indication for referral to a neurologist for long-term follow-up is assessed.
Headaches can be separated into four groups: (1) recent onset and thunderclap; (2) recent onset with progressive installation: (3) well known to the patient and episodic (attacks with headache-free periods, as in episodic migraine or cluster headache); and (4) chronic daily headaches (more than 3 months, more than 15 days of headache per month). Headaches with a recent onset and judged unusual or worrisome by the patient (even one with frequent headaches) must raise the suspicion of a secondary cause and need to be investigated. Headaches that continue for months or years are more often primary, but secondary causes need to be ruled out in certain cases.
Gross xanthochromia on lumbar puncture may not represent an acute subarachnoid hemorrhage
2009, American Journal of Emergency Medicine
Citation Excerpt :
Headache is a common complaint in the emergency department (ED), representing approximately 1% to 4% of all ED visits [1-4], with a recent survey showing headache making up 2.2% of all ED visits [5].
Headache is a common presenting complaint in the emergency department (ED) that sometimes requires a diagnostic workup including a lumbar puncture (LP). An LP is often used to evaluate patients in the ED for an acute neurologic process. Xanthochromia seen on cerebrospinal fluid from an LP is often considered to be highly suggestive of a subarachnoid hemorrhage. We describe 2 cases where gross xanthochromia was noted during LP but the patients did not have an acute subarachnoid hemorrhage.

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Original contributionNon-traumatic headache in the emergency department

Lancet

Med Clin North Am

Med Clin North Am

JACEP

JACEP

Med Clin North Am

JACEP

Med Clin North Am

Hospital Emergency Room Utilization Study

The management of non-traumatic headache in a university hospital emergency room

Headache

Use of the hospital emergency room in relation to use of private physicians

Public Health Briefs

Original contribution
Non-traumatic headache in the emergency department