ACEP Clinical Policy: ACEP Clinical Policy: Adult Headache PatientsAdult Headache Patients

2010 Clinical Decision Making in Emergency Medicine

Ponte Vedra Beach, FLPonte Vedra Beach, FL

June 24, 2010June 24, 2010

Edward P. Sloan, MD, MPH FACEP

Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL

Attending PhysicianEmergency Medicine

University of Illinois HospitalSwedish American Belvidere Hospital

Chicago, IL

DisclosuresDisclosures• FERNE Chairman and PresidentFERNE Chairman and President• FERNE advisory board for The Medicine FERNE advisory board for The Medicine

Company in May 2007Company in May 2007

• No current individual financial No current individual financial disclosuresdisclosures

Case PresentationsCase Presentations• 35 year old female presents with a 35 year old female presents with a

diffuse headache that is worse than her diffuse headache that is worse than her normal migraine headache. She states normal migraine headache. She states that this is “the worst headache of her that this is “the worst headache of her life”. She is nauseated and has life”. She is nauseated and has vomited one time. Her migraine vomited one time. Her migraine medicines have not helped to resolve medicines have not helped to resolve the headache pain.the headache pain.

Case PresentationsCase Presentations• 45 year old female presents with a 45 year old female presents with a

sudden, severe headache that began sudden, severe headache that began while she was lifting weights at the while she was lifting weights at the gym. She states that it felt “like gym. She states that it felt “like someone hit her on the head with a someone hit her on the head with a baseball bat”. She has photophobia, baseball bat”. She has photophobia, vomiting, neck pain, and meningismus vomiting, neck pain, and meningismus on physical exam.on physical exam.

Key Clinical QuestionsKey Clinical Questions• What are the likely diagnoses What are the likely diagnoses

and life threats in these two and life threats in these two patients?patients?

Key Clinical QuestionsKey Clinical Questions• What is the best approach to What is the best approach to

the diagnosis of these two the diagnosis of these two Emergency Department Emergency Department headache patients?headache patients?

Key Clinical QuestionsKey Clinical Questions• What tests must be performed in What tests must be performed in

order to exclude the life threats order to exclude the life threats for these patients so that they can for these patients so that they can be sent home once the headache be sent home once the headache has resolved?has resolved?

A Negative CT ScanA Negative CT Scan

Recommendation StrengthRecommendation Strength• Level A recommendations. Level A recommendations. • Generally accepted principles for Generally accepted principles for

patient management that reflect a high patient management that reflect a high degree of clinical certainty (ie, based on degree of clinical certainty (ie, based on strength of evidence Class I or strength of evidence Class I or overwhelming evidence from strength overwhelming evidence from strength of evidence Class II studies that directly of evidence Class II studies that directly address all of the issues).address all of the issues).

Recommendation StrengthRecommendation Strength• Level B recommendations.  Level B recommendations.  • Recommendations for patient management Recommendations for patient management

that may identify a particular strategy or that may identify a particular strategy or range of management strategies that reflect range of management strategies that reflect moderate clinical certainty (ie, based on moderate clinical certainty (ie, based on strength of evidence Class II studies that strength of evidence Class II studies that directly address the issue, decision analysis directly address the issue, decision analysis that directly addresses the issue, or strong that directly addresses the issue, or strong consensus of strength of evidence Class III consensus of strength of evidence Class III studies).studies).

Recommendation StrengthRecommendation Strength• Level C recommendations. Level C recommendations. • Other strategies for patient Other strategies for patient

management that are based on management that are based on preliminary, inconclusive, or preliminary, inconclusive, or conflicting evidence, or in the conflicting evidence, or in the absence of any published absence of any published literature, based on panel literature, based on panel consensus.consensus.

Question 1:Question 1:• Does a response to therapy predict Does a response to therapy predict

the etiology of an acute headache?the etiology of an acute headache?  

• Level C recommendations. Level C recommendations.   

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

Question 2:Question 2:• Which patients with headache Which patients with headache

require neuroimaging in the ED?require neuroimaging in the ED?• Level B recommendations.Level B recommendations.• 1. Patients presenting to the ED with 1. Patients presenting to the ED with

headache and new abnormal findings in headache and new abnormal findings in a neurologic examination (eg, focal a neurologic examination (eg, focal deficit, altered mental status, altered deficit, altered mental status, altered cognitive function) should undergo cognitive function) should undergo emergent* non-contrast head CT.emergent* non-contrast head CT.

Question 2:Question 2:• Which patients with headache Which patients with headache

require neuroimaging in the ED?require neuroimaging in the ED?• Level B recommendations.Level B recommendations.

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

Question 2:Question 2:• Which patients with headache Which patients with headache

require neuroimaging in the ED?require neuroimaging in the ED?• Level B recommendations.Level B recommendations.  • 3. HIV-positive patients with a new type 3. HIV-positive patients with a new type

of headache should be considered for of headache should be considered for an emergent* neuroimaging study.an emergent* neuroimaging study.

Question 2:Question 2:• Which patients with headache Which patients with headache

require neuroimaging in the ED?require neuroimaging in the ED?• Level C recommendations.Level C recommendations.• Patients who are older than 50 years Patients who are older than 50 years

and presenting with new type of and presenting with new type of headache but with a normal headache but with a normal neurological examination should be neurological examination should be considered for an urgent† considered for an urgent† neuroimaging study.neuroimaging study.

Question 3:Question 3:• Does lumbar puncture need to be Does lumbar puncture need to be

routinely performed on ED patients routinely performed on ED patients being worked up for non-traumatic being worked up for non-traumatic subarachnoid hemorrhage whose subarachnoid hemorrhage whose non-contrast brain CT scans are non-contrast brain CT scans are interpreted as normal?interpreted as normal?

Question 3:Question 3:• Level B recommendations. Level B recommendations. • In patients presenting to the ED with In patients presenting to the ED with

sudden-onset, severe headache and a sudden-onset, severe headache and a negative non-contrast head CT scan negative non-contrast head CT scan result, lumbar puncture should be result, lumbar puncture should be performed to rule out subarachnoid performed to rule out subarachnoid hemorrhage.hemorrhage.

Question 4:Question 4:• In which adult patients with a In which adult patients with a

complaint of headache can a lumbar complaint of headache can a lumbar puncture be safely performed puncture be safely performed without a neuroimaging study?without a neuroimaging study?

  

Question 4:Question 4:• Level C recommendations.Level C recommendations.

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

Question 4:Question 4:• Level C recommendations.Level C recommendations.• 2. In the absence of clinical findings 2. In the absence of clinical findings

suggestive of increased intracranial suggestive of increased intracranial pressure, a lumbar puncture can be pressure, a lumbar puncture can be performed without obtaining a performed without obtaining a neuroimaging study. neuroimaging study. (Note: An LP (Note: An LP does not assess for all causes of a does not assess for all causes of a sudden severesudden severe headache.)headache.)

Questions 5:Questions 5:• Is there a need for further emergent Is there a need for further emergent

diagnostic imaging in the patient diagnostic imaging in the patient with sudden-onset, severe with sudden-onset, severe headache who has negative headache who has negative findings in both CT and lumbar findings in both CT and lumbar puncture?puncture?

Questions 5:Questions 5:• Level B recommendations. Level B recommendations. • Patients with a sudden-onset, severe Patients with a sudden-onset, severe

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

ConclusionsConclusions• Guidelines do provide guidance

• Clinically relevant clinical questions with specific answers

• Assists the clinician in decision making

• Pt outcomes can be optimized

• Clinical practice enhanced

Questions?Questions?edsloan@uic.edu312 317 4996

www.ferne.org

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