Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache
Official 2019 guideline from the American College of Emergency Physicians.
summary by Eric Steinberg, DO, MEHP
Diagnosis
Risk Stratification
Use the Ottawa Subarachnoid Hemorrhage Rule (>40 years, complaint of neck pain or stiffness, witnessed loss of consciousness, onset with exertion, thunderclap headache, and limited neck flexion on examination) as a decision rule that has high sensitivity to rule out subarachnoid hemorrhage, but low specificity to rule in subarachnoid hemorrhage, for patients presenting to the emergency department with a normal neurologic examination result and peak headache severity within 1 hour of onset of pain symptoms.
Level B
Although the presence of neck pain and stiffness on physical examination in emergency department patients with an acute headache is strongly associated with subarachnoid hemorrhage, do not use a single physical sign and/or symptom to rule out subarachnoid hemorrhage.
Level B
Further Diagnostic Testing
Use a normal noncontrast head computed tomography* performed within 6 hours of symptom onset in an emergency department headache patient with a normal neurologic examination, to rule out nontraumatic subarachnoid hemorrhage.
*Minimum third-generation scanner.
*Minimum third-generation scanner.
Level B
Lumbar Puncture
Perform lumbar puncture or computed tomography angiography to safely rule out subarachnoid hemorrhage in the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography result.
Level C
Use shared decision making to select the best modality for each patient after weighing the potential for false-positive imaging and the pros and cons associated with lumbar puncture.
Level C
Treatment
Nonopioid Medications
Preferentially use nonopioid medications in the treatment of acute primary headaches in emergency department patients.
Level A
What do the icons mean?
Level A
Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).Level B
Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).Level C
Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus.
