Semin Neurol 2019; 39(01): 020-026
DOI: 10.1055/s-0038-1677023
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Evaluation and Management of the Emergency Department Headache

Levi Filler
1   Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona
,
Murtaza Akhter
1   Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona
2   Department of Emergency Medicine, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
,
Perrin Nimlos
1   Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona
› Author Affiliations
Further Information

Publication History

Publication Date:
11 February 2019 (online)

Abstract

The acute headache in the emergency department (ED) poses a diagnostic dilemma that may overwhelm providers attempting to weigh the cost of advanced workups against the risk of missing serious pathology. While the majority of headache concerns are benign primary headache disorders, identifying life-threatening secondary causes of headache—which may be broadly categorized into structural, infectious, and vascular causes—is the primary focus of evaluation in the ED. Secondary headaches are associated with a high morbidity and mortality, and require strict scrutiny of the history and physical examination to adequately risk-stratify patients. Innovative and emerging technologies may further assist providers in the diagnosis of headache, and challenge previous gold-standard diagnostic evaluations. Herein, we present a general overview of the workup and management of headaches in the ED, with a special section for diagnostic considerations in evaluating for acute meningitis, subarachnoid hemorrhage, and acute angle-closure glaucoma.

 
  • References

  • 1 Augustine JJ. Emergency Department Benchmarking Alliance Releases 2014 Data on Staffing, Physician Productivity. ACEPNow January 15, 2016
  • 2 Goldstein JN, Camargo Jr CA, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia 2006; 26 (06) 684-690
  • 3 Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33 (09) 629-808
  • 4 Singh A, Soares WE. Management strategies for acute headache in the emergency department. Emerg Med Pract 2012; 14 (06) 1-23 , quiz 23–24
  • 5 Practice parameters: the utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations (summary statements). Report of the quality standards subcommittee of the American Academy of Neurology. Neurology 1994; 44: 1353-1354
  • 6 Harrigan M, Felix ACG. Headache. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD. , eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw Hill; 2017
  • 7 Steigbigel NH. Computed tomography of the head before a lumbar puncture in suspected meningitis -- is it helpful?. N Engl J Med 2001; 345 (24) 1768-1770
  • 8 Attia J, Hatala R, Cook DJ, Wong JG. The rational clinical examination. Does this adult patient have acute meningitis?. JAMA 1999; 282 (02) 175-181
  • 9 Newman DH. Evidence-based emergency medicine. Clinical assessment of meningitis in adults. Ann Emerg Med 2004; 44 (01) 71-73
  • 10 Waghdhare S, Kalantri A, Joshi R, Kalantri S. Accuracy of physical signs for detecting meningitis: a hospital-based diagnostic accuracy study. Clin Neurol Neurosurg 2010; 112 (09) 752-757
  • 11 Nakao JH, Jafri FN, Shah K, Newman DH. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med 2014; 32 (01) 24-28
  • 12 Lemonick DM. Subarachnoid hemorrhage: state of the art(ery). Am J Chin Med 2010; 7 (02) 64
  • 13 Behrouz R, Birnbaum LA, Jones PM, Topel CH, Misra V, Rabinstein AA. Focal neurological deficit at onset of aneurysmal subarachnoid hemorrhage: frequency and causes. J Stroke Cerebrovasc Dis 2016; 25 (11) 2644-2647
  • 14 Perry JJ. Subarachnoid Hemorrhage. In: Rowe BH. , ed. Evidence Based Emergency Medicine. 1st ed. Chichester, UK: John Wiley & Sons Ltd; 2009: 485-492
  • 15 Landtblom A-M, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia 2002; 22 (05) 354-360
  • 16 Linn FH, Rinkel GJ, Algra A, van Gijn J. Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke 1996; 27 (04) 625-629
  • 17 Singer RJ, Ogilvy CS, Rordorf G. Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage - UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aneurysmal-subarachnoid-hemorrhage . Accessed January 8, 2019
  • 18 Backes D, Rinkel GJE, Sturkenboom AJM, Vergouwen MDI. Time-dependent test characteristics of neck stiffness in patients suspected of nontraumatic subarachnoid haemorrhage. J Neurol Sci 2015; 355 (1–2): 186-188
  • 19 Bor ASE, Rinkel GJE, Adami J. , et al. Risk of subarachnoid haemorrhage according to number of affected relatives: a population based case-control study. Brain 2008; 131 (Pt 10): 2662-2665
  • 20 Perry JJ, Stiell IG, Sivilotti ML. , et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA 2013; 310 (12) 1248-1255
  • 21 Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. ; American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008; 52 (04) 407-436
  • 22 Connolly Jr ES, Rabinstein AA, Carhuapoma JR. , et al; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; 43 (06) 1711-1737
  • 23 Evans RW. Complications of lumbar puncture. Neurol Clin 1998; 16 (01) 83-105
  • 24 Perry JJ, Stiell IG, Sivilotti MLA. , et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011; 343 (18) d4277-d4277
  • 25 Probst MA, Hoffman JR. Computed tomography angiography of the head is a reasonable next test after a negative noncontrast head computed tomography result in the emergency department evaluation of subarachnoid hemorrhage. Ann Emerg Med 2016; 67 (06) 773-774
  • 26 McCormack RF, Hutson A. Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan?. Acad Emerg Med 2010; 17 (04) 444-451
  • 27 Flaherty ML, Haverbusch M, Kissela B. , et al. Perimesencephalic subarachnoid hemorrhage: incidence, risk factors, and outcome. J Stroke Cerebrovasc Dis 2005; 14 (06) 267-271
  • 28 MacKinnon AD, Clifton AG, Rich PM. Acute subarachnoid haemorrhage: is a negative CT angiogram enough?. Clin Radiol 2013; 68 (03) 232-238
  • 29 Sun X, Dai Y, Chen Y. , et al. Primary angle closure glaucoma: what we know and what we don't know. Prog Retin Eye Res 2017; 57: 26-45
  • 30 Kwiatkowski T, Friedman B. Headache Disorders. In: Marx J, Hockberger R, Walls R. , eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 65, 8th ed. Philadelphia, PA: Elsevier Saunders; 2013
  • 31 Broder J, Preston R. Imaging the head and brain. In: Broder J, ed. Diagnostic Imaging for the Emergency Physician. Philadelphia, PA: Elsevier Saunders; 2011: 1-45
  • 32 Robertson JJ, Koyfman A. Cervical artery dissections: a review. J Emerg Med 2016; 51 (05) 508-518
  • 33 Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Neurology 2012; 78 (17) 1337-1345
  • 34 Marx JA, Hockberger RS, Walls RM, Adams J, Rosen P. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 14. Philadelphia, PA: Elsevier Saunders; 2010
  • 35 Friedman BW, Grosberg BM. Diagnosis and management of the primary headache disorders in the emergency department setting. Emerg Med Clin North Am 2009; 27 (01) 71-87 , viii
  • 36 Myers DE, Myers RA. A preliminary report on hyperbaric oxygen in the relief of migraine headache. Headache 1995; 35 (04) 197-199