Picture the scene…
You see a patient in the “Ambulatory” area of the ED, who has a headache. The triage simply says “headache not like his usual migraine”
To learn about the management of the patient with headache in the Emergency Department.
Task 1 – Read
Read this blog post from RCEM Learning1. Note that often the ED approach is “rule out the worst case scenario”, rather than “make a diagnosis”. In patients with headache the key diagnoses we want to rule out is subarachnoid haemorrhage, with meningitis, tumours and temporal arteritis close behind.
Task 3 – Discuss
This part of the teaching session should be lead by an experienced clinician. The cases provided are merely examples and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice.
Case 1 – A patient with headache
A 55 year old presents with an intermittant severe, headache. It’s throbbing in nature and localised to the fronto-temporal region. She is apyrexial.
1, What particular points will you ask about in the history?
That the headache is intermittant and mostly located over the front of the head makes subarachnoid haemorrhage less likely. It would be important to seek out other symptoms that may indicare temporal (giant cell) arteritis, such as: jaw claudication; fatigue; weight loss and night sweats.
2,What features would you look for on examination
There may be tenderness over the temples and loss of pulsation of the temporal artery. You should check visual acuity – visual loss can occur in up to 30% of patients3.
3, What investigations would confirm the diagnosis?
Although often the ESR and CRP are raised they may be normal. The diagnosis would be confirmed by a temproal artery biopsy, which should be performed within one week of symptom onset.
You may consider a CT scan of the brain to rule out other intracranial pathology such as a tumour.
4, What treatment would you give?
The patient should immediately be started on high dose steroids: if no visual symptoms are present 46-60mg/day, if thereare visual symptoms 60-100mg/day4.
The patient should urgently be referred to a rhematologist (plus an opthalmologist if visual symptoms are present).
Case 2 – A patient with sudden onset headache
A 59 year old woman presents to the ED with a sudden onset occipital headache. The headache reached its peak within a few minutes.
1, What are the key questions to ask in the history?
The history is very suggestive of a subarachnoid haemorrhage. Subjective neck stiffness (LR+4.12) increases the likelihood of the diagnosis, whilst the absence of “worst headache of my life” (LR- 0.36) and onset of over one hour (LR-0.06) make it less likely5. Symptoms can last for weeks, and whilst adverse features such as nausea, vomiting, neurology, seizures, neck pain and stiffness, confusion, and decreased conscious level are uncommon, the absence of these does not immediately rule out SAH6.
2, What would you look for on a focussed examination?
Neck stiffness is strongly associated with SAH (LR+ 6.59)5 but no other examination finding is particularly helpful.
3, What investigations would you request?
Traditionally, if SAH is suspected all patients have needed both a CT scan and a lumbar puncture to either confirm or rule out the diagnosis.
There has been some recent evidence that in certain groups a negative CT scan alone may be enough to rule out the diagnosis7. Can depend on the type of CT scanner available and the approach of your radiology (and other) colleagues.
Task 4 – Summary
In this session we have learned about the clinical assessment of the patient with headache in the Emergency Department
Consider these questions based on your learning today
1, What are the causes of headache that we must rule out in the Emergency Deartment?
- Subarachnoid haemorrhage
- Temporal (Giant Cell) arteritis
- Space occupying lesion/tumour
2, What are the “Red Flags” in the history that suggest a serious cause of headache?
- Sudden onset headache
- Onset during exercise or that are present on waking
- First and worst – headache in patients who don’t have frequent headaches or migraines and severe headache particularly if described as “the worst headache of my life”
- Headaches in the context of fever or seizure
- Occipital headache
Task 5 – Reflect
In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.
Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.
Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?
References and Further Reading
- 1Neill A. Induction – Headache. RCEM Learning. 2018; published online Feb 6. https://www.rcemlearning.co.uk/foamed/induction-headache/ (accessed June 6, 2020).
- 2May N. I Can’t Get You Out of my Head – Headache at St Emlyns. St Emlyn’s. 2014; published online Jan 8. https://www.stemlynsblog.org/induction-headache/ (accessed June 6, 2020).
- 3Mann C. Temporal Arteritis. RCEM Learning. 2012; published online July 10. https://www.rcemlearning.co.uk/modules/secondary-headache/lessons/extracranial-pathology/topic/temporal-arteritis/ (accessed June 6, 2020).
- 4Giant Cell Arteritis. NICE, 2020.
- 5Carpenter CR, Hussain AM, Ward MJ, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Acad Emerg Med 2016; : 963–1003.
- 6Gray C. Let’s talk about subarachnoid haemorrhage. St Emlyn’s. 2016; published online Jan 7. https://www.stemlynsblog.org/lets-talk-about-subarachnoid-haemorrhage/ (accessed June 6, 2020).
- 7Sayer D, Bloom B, Fernando K, et al. An Observational Study of 2,248 Patients Presenting With Headache, Suggestive of Subarachnoid Hemorrhage, Who Received Lumbar Punctures Following Normal Computed Tomography of the Head. Acad Emerg Med 2015; : 1267–73.