Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache

Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study

BACKGROUND

People presenting to the ED with acute severe headache often undergo investigation to exclude subarachnoid haemorrhage (SAH). International guidelines propose that brain imaging within 6 hours of headache onset can exclude SAH, in isolation. The safety of this approach is debated. We sought to externally validate this strategy and evaluate the test characteristics of CT-brain beyond 6 hours.

METHODS

A prospective, multicentre, observational cohort study of consecutive adult patients with non-traumatic acute headache presenting to the ED within a UK National Health Service setting. Investigation, diagnosis and management of SAH were all performed within routine practice. All participants were followed up for 28 days using medical records and direct contact as necessary. Uncertain diagnoses were independently adjudicated.

RESULTS

Between March 2020 and February 2023, 3663 eligible patients were enrolled from 88 EDs (mean age 45.8 (SD 16.6), 64.1% female). 3268 patients (89.2%) underwent CT-brain imaging. There were 237 cases of confirmed SAH, a prevalence of 6.5%. CT within 6 hours of headache onset (n=772) had a sensitivity of 97% (95% CI 92.5% to 99.2%) for the diagnosis of SAH and a negative predictive value of 99.6% (95% CI 98.9% to 99.9%). The post-test probability after a negative CT within 6 hours was 0.5% (95% CI 0.2% to 1.3%). The negative likelihood ratio was 0.03 (95% CI 0.01 to 0.08). CT within 24 hours of headache onset (n=2008) had a sensitivity of 94.6% (95% CI 91.0% to 97.0%). Post-test probability for SAH was consistently less than 1%. For aneurysmal SAH, post-test probability was 0.1% (95% CI 0.0% to 0.4%) if the CT was performed within 24 hours of headache onset.

CONCLUSION

Our data suggest a very low likelihood of SAH after a negative CT-brain scan performed early after headache onset. These results can inform shared decision-making on the risks and benefits of further investigation to exclude SAH in ED patients with acute headache.

Diagnostic workup of acute headache and subarachnoid hemorrhage in a Norwegian population: An observational study

BACKGROUND

Acute headache may be the primary symptom of subarachnoid hemorrhage (SAH). Recent guidelines suggest that non-contrast computed tomography (CT) is adequate to exclude aneurysmal SAH if performed within 6 h after symptom onset. However, most studies of acute headache including CT, lumbar puncture and SAH are multicenter studies from referral hospitals with highly selected patient populations. The main purpose of this study was to describe the diagnostic properties of head CT and cerebrospinal fluid (CSF) spectrophotometry for detecting SAH in an unselected primary hospital population with acute headache.

METHODS

A retrospective cross-sectional study conducted at a large primary hospital serving roughly 10% of the Norwegian population. Diagnostic workup from consecutive patients evaluated for acute headache in 2009-2020 were collected. All CSF-spectrophotometry reports were standardized and the same CT scanner was used during the study.

RESULTS

A total of 3227 patients were included. Median age was 45 years and 63% were women. In total, 170 (5.3% of all acute headache patients) had SAH. Of 3071 CT-negative patients, 2852 (93%) underwent lumbar puncture. Of the CSF reports, 2796 (98%) were negative for xanthochromia. Overall, the rate for detection of aneurysmal SAH by positive xanthochromia was 9 in 2852 cases (3‰). The miss rate for the detection of an aneurysmal SAH with a CT scan within 6 h was 0 and within 12 h 1 in 2852 cases (0.3‰).

CONCLUSION

In acute headache, a CT scan taken within 6 h is practically 100% sensitive for detecting any SAH.

Epidemiology of headache presentations to United States emergency departments from 2016 to 2023

INTRODUCTION

Headaches are a common condition seen in the Emergency Department (ED), with numerous trials focused on improving care for these patients. However, there is limited recent large-scale, robust data available on the incidence, admission rates, evaluation, and treatment in the ED setting.

METHODS

This was a cross-sectional study of ED presentations for headache from 1/1/2016 to 12/31/2023 using the Epic Cosmos national database. All ED visits with headache-relevant ICD-10 coding were included. Outcomes included percentage of total ED visits, admission rates, computed tomography (CT) brain imaging, lumbar puncture (LP) performance, and medication administration. Medications were analyzed by class (NSAIDs, acetaminophen, dopamine antagonists, diphenhydramine, opioids, intravenous fluids, caffeine, and magnesium sulfate). Subgroup analyses were performed by specific types of dopamine antagonists.

RESULTS

Of 188,482,644 ED encounters, 6,007,090 (3.2%) were due to headache. Of these, 246,082 (4.1%) were admitted. Nearly half (46.6%) of patients received at least one CT. Rates of CT head without contrast increased from 38.2% to 47.9% over time, while rates of CT angiography rose from 2.8% to 10.2%. 1.4% of all patients received an LP, with rates decreasing from 1.8% to 1.1% over time. The most common medication was NSAIDs (45.3%), followed by dopamine antagonists (44.8%), diphenhydramine (38.1%), acetaminophen (24.8%), opioids (16.3%), magnesium sulfate (0.2%), and caffeine (0.1%). 50.8% of patients received intravenous fluids. Rates of opioids declined over time, while dopamine antagonists, acetaminophen, and intravenous fluid administration increased.

CONCLUSION

Headaches represent a common reason for ED presentation, with approximately 4% of patients being admitted. Imaging is frequently performed, with rises in CT without contrast and CT angiography rates over time, while LP rates have been declining. NSAIDs remain the most common medication given, with opioids declining over time while non-opioid agents such as dopamine antagonists have increased. These findings can help inform health policy initiatives, such as those focused on radiologic imaging and evidence-based medication administration.

Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era

PURPOSE

To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018).

MATERIALS AND METHODS

We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization.

RESULTS

Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05).

CONCLUSIONS

We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.

Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021

Importance

Subarachnoid hemorrhage is typically diagnosed by noncontrast head computed tomography (CT); lumbar puncture is recommended if computed tomography is nondiagnostic, although CT cerebral angiography has been promoted as an alternative to lumbar puncture in this diagnostic pathway. The outcomes of this debate in practice have not been studied.

Objective

To determine whether CT cerebral angiography use has increased in lieu of lumbar puncture among emergency department (ED) patients with headache, with an increase in unruptured intracranial aneurysm detection.

Design, Setting, and Participants

This retrospective cohort study took place in 21 community EDs of an integrated health care system in Northern California between 2015 and 2021. Participants were adult (aged >17 years) health plan members with a chief concern of headache. Exclusions were prior diagnoses of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral arteriovenous malformation, or cerebrospinal fluid shunt. Data were analyzed from October to November 2023.

Exposures

CT cerebral angiography and/or lumbar puncture during the ED encounter.

Main Outcomes and Measures

Primary and secondary outcomes were 14-day and 90-day unruptured intracranial aneurysm detection, respectively. Safety outcomes were missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. The annual incidence of unruptured intracranial aneurysm detection was normalized to the incidence of subarachnoid hemorrhage (UIA:SAH ratio). Average annualized percentage changes were quantified using joinpoint regression analysis.

Results

Among 198 109 included ED encounters, the mean (SD) age was 47.5 (18.4) years; 140 001 patients (70.7%) were female; 29 035 (14.7%) were Black or African American, 59 896 (30.2%) were Hispanic or Latino, and 75 602 (38.2%) were White. Per year, CT cerebral angiography use increased (18.8%; 95% CI, 17.7% to 20.3%) and lumbar punctures decreased (-11.1%; 95% CI, -12.0% to -10.4%), with a corresponding increase in the 14-day UIA:SAH ratio (3.5%; 95% CI, 0.9% to 7.4%). Overall, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of UIA. Results were similar at 90 days and robust to sensitivity analyses. Subarachnoid hemorrhage (1004 cases) and bacterial meningitis (118 cases) were misdiagnosed in 5% and 18% of cases, respectively, with no annual trends (P = .34; z1003 = .95 and P = .74; z117 = -.34, respectively).

Conclusions and Relevance

In this cohort study of ED patients with headache, increases in CT cerebral angiography use were associated with fewer lumbar punctures and higher detection of unruptured intracranial aneurysms, with no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. While this shift in diagnostic strategy appeared safe in the short-term, the long-term consequences remain unclear.

Ominous Causes of Headache

PURPOSE OF REVIEW

While primary headaches like migraines or cluster headaches are prevalent and often debilitating, it's the secondary headaches-those resulting from underlying pathologies-that can be particularly ominous. This article delves into the sinister causes of headaches, underscoring the importance of a meticulous clinical approach, especially when presented with red flags.

RECENT FINDINGS

Headaches, one of the most common complaints in clinical practice, span a spectrum from benign tension-type episodes to harbingers of life-threatening conditions. For the seasoned physician, differentiating between these extremes is paramount. Headache etiologies covered in this article will include subarachnoid hemorrhage (SAH), cervical artery dissection, cerebral venous thrombosis, meningitis, obstructive hydrocephalus, and brain tumor.

The Effect of Language on the Decision to Image in the Evaluation of Atraumatic Headache

BACKGROUND

Patients with limited English proficiency seen in the emergency department (ED) experience lower quality of care and higher diagnostic resource utilization unless they are evaluated in their own language. Despite a low rate of serious pathology identified and the availability of guidelines to direct its use, computed tomography (CT) is commonly used to evaluate atraumatic headache in the ED.

OBJECTIVE

Our aim was to determine whether Spanish-speaking patients with atraumatic headache were more likely than their English-speaking counterparts to undergo head CT, and whether evaluation by a clinician who passed a Spanish proficiency test mitigated this difference.

METHODS

This retrospective observational study used electronic health record data of adult patients presenting with atraumatic headache to a level I trauma center during a 2-year period. Spanish-language testing of clinicians consisted of a brief, unvalidated, in-person, nonmedical verbal test administered by human resources staff.

RESULTS

A total of 3030 patients with atraumatic headache were identified; 1437 were English speaking and 1593 were Spanish speaking. Spanish-speaking patients were older (48.3 vs. 41.9 years), more likely to be women (68.8% vs. 60.5%), and more likely to undergo head CT (31.8% vs. 26.4%). Evaluation by a clinician who passed the Spanish proficiency test had no significant influence on the likelihood of head CT for Spanish-speaking patients after controlling for confounding variables (adjusted odds ratio 0.95; 95% CI 0.75-1.20).

CONCLUSIONS

Spanish-speaking patients are more likely to undergo head CT when evaluated for atraumatic headache than English-speaking patients. Evaluation by a clinician who passed a brief Spanish proficiency test did not mitigate this disparity.

Managing and Preventing Migraine in the Emergency Department: A Review

Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.

The Italian hub-and-spoke network for the emergency neurology management

OBJECTIVE

The aim of the present study was to assess emergency neurology management in Italy by comparing patients admitted to the hub and spoke hospitals.

METHODS

Data obtained from the annual Italian national survey (NEUDay) investigating the activity and facilities of neurology in the emergency room conducted in November 2021 were considered. Information for each patient who received a neurologic consultation after accessing the emergency room was acquired. Data on facilities were also gathered, including hospital classification (hub vs spoke), number of consultations, presence of neurology and stroke unit, number of beds, availability of neurologist, radiologist, neuroradiologist, and instrumental diagnostic accessibility.

RESULTS

Overall, 1,111 patients were admitted to the emergency room and had neurological consultation across 153 facilities (out of the 260 Italian ones). Hub hospitals had significantly more beds, availability of neurological staff, and instrumental diagnostic accessibility. Patients admitted to hub hospital had a greater need for assistance (higher number of yellow/red codes at neurologist triage). A higher propensity to be admitted to hub centers for cerebrovascular problems and to receive a diagnosis of stroke was observed.

CONCLUSIONS

The identification of hub and spoke hospitals is strongly characterized by the presence of beds and instrumentation mainly dedicated to acute cerebrovascular pathologies. Moreover, the similarity in the number and type of accesses between hub and spoke hospitals suggests the need to look for adequate identification of all the neurological pathologies requiring urgent treatment.

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness

Objective

Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients.

Methods

This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention.

Results

Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation.

Conclusion

Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

ACR Appropriateness Criteria® Headache: 2022 Update

Headache is an ancient problem plaguing a large proportion of the population. At present, headache disorders rank third among the global causes of disability, accounting for over $78 billion per year in direct and indirect costs in the United States. Given the prevalence of headache and the wide range of possible etiologies, the goal of this document is to help clarify the most appropriate initial imaging guidelines for headache for eight clinical scenarios/variants, which range from acute onset, life-threatening etiologies to chronic benign scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Study about the Manchester Triage System subtriage in patients that visited the Emergency Department due to headache

INTRODUCTION

Headache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the emergency department due to headache.

MATERIAL AND METHODS

We studied a series of consecutive patients who came to the emergency department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned.

RESULTS

We registered a total of 1120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, 2 patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and 5 as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level.

CONCLUSION

During the study period, at least one in 10 patients attending the emergency department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

Diagnostic yield, indications, and outcomes of cranial imaging in AML patients admitted for intensive induction or consolidation chemotherapy: a single-center experience

Cranial imaging (CI) is a widely used diagnostic procedure, especially in acute myeloid leukemia (AML) patients with suspected bleeding or infection. However, common clinical decision rules to guide CI do not apply to AML patients and the diagnostic yield and outcomes of CI for AML patients are largely unknown. We retrospectively evaluated all CI from newly diagnosed non-promyelocytic AML patients receiving intensive induction or consolidation chemotherapy between 2007 and 2019 for imaging indications, diagnostic yield, and consequences. A total of 110 of 462 patients (24%) received CI for 152 imagings in distinct clinical situations. Forty-four patients (40%) had at least one new and acute pathological finding. Main indication was focal neurologic deficit, craniocerebral trauma, and suspected cerebral hypertension. The most common new finding was intracranial hemorrhage (13% of all imagings), followed by sinusitis (9%). CI led to therapy change in 21 patients. There were no clear associations between indications, laboratory values, and a positive imaging. Positive imaging was associated with adverse overall survival. Our study suggests that the overall rate of ordered CI was appropriate and that CI should generally be performed at a low threshold. A systematized approach to CI may further increase diagnostic yield but is complicated by variable clinical presentation.

Primary Headache Approach in the Emergency Departments: A Systematic Scoping Review of Prospective Studies

This systematic scoping review aims to answer questions related to the main characteristics of primary headache, the need for neuroimaging, and the presence of red flags in these patients. A review of prospective studies including the MEDLINE/PubMed, Scopus, LILACS, and SCIELO databases, as well as the grey literature, was conducted. The methodological quality of the selected investigations was also assessed. Six investigations met the selection criteria. The mean age of people with primary headache was less than 43 years, with ages ranging from 39 to 46 years. Most of the studies reported the presence of nausea/vomiting, between 12% and 60% of the patients studied. To a lesser extent, there was also the presence of intense and moderate pain, loss of consciousness, stiff neck, presence of aura, and photophobia. The most frequent diagnoses were unspecified headache, migraine, and tension headache. The studies did not recommend neuroimaging and no red flags were reported. Primary headache occurred more frequently in women, in those under 46 years of age with a history of migraine and similar episodes. Moreover, the presence of red flags and the need for neuroimaging in patients with primary headaches were not evidenced.

Quality Improvement in the Management of Subarachnoid Hemorrhage: Current State and Future Directions

PURPOSE OF REVIEW

Aneurysmal subarachnoid hemorrhage carries high mortality and morbidity. Quality improvement (QI) efforts in the management of this disease process are growing as the field of neurocritical care matures. This review provides updates in QI in subarachnoid hemorrhage (SAH) and discusses gaps and future directions.

RECENT FINDINGS

Literature published on the topic over the past 3 years were evaluated. An assessment of current QI practices pertaining to the acute care of SAH was conducted. These include processes surrounding acute pain management, inter-hospital coordination of care, complications during the initial hospital stay, role of palliative care, and quality metrics collection, reporting, and monitoring. SAH QI initiatives have shown promise by decreasing ICU and hospital lengths of stay, health care costs, and hospital complications. The review reveals substantial heterogeneity, variability, and limitations in SAH QI protocols, measures, and reporting. Uniformity in QI research, implementation, and monitoring will be crucial as disease-specific QI develops in neurological care.

Update on primary headache associated with sexual activity and primary thunderclap headache

BACKGROUND

This narrative review aims to provide an update on primary headache associated with sexual activity and primary thunderclap headache.

METHODS

We conducted a literature search on PubMed with the keywords "headache associated with sexual activity", "sexual headache", "orgasmic cephalalgia", and "coital cephalalgia" in addition to "thunderclap headache" to assess the appropriateness of all published articles in this review.

RESULTS

Primary headache associated with sexual activity is a "primary" headache precipitated by sexual activity, which occurs as sexual excitement increases (progressive at onset), or manifests as an abrupt and intense headache upon orgasm (thunderclap at onset) or combines these above two features. Primary headache associated with sexual activity is diagnosed after a thorough investigation, including appropriate neuroimaging studies, to exclude life-threatening secondary causes such as subarachnoid hemorrhage. According to the criteria of the third edition of the International Classification of Headache Disorders, primary thunderclap headache is also a diagnosis by exclusion. The pathophysiology of primary headache associated with sexual activity and primary thunderclap headache remains incompletely understood. Treatment may not be necessary for all patients since some patients with primary headache associated with sexual activity and primary thunderclap headache have a self-limiting course.

CONCLUSION

A comprehensive neuroimaging study is needed for distinguishing primary headache associated with sexual activity or primary thunderclap headache from secondary causes. Primary headache associated with sexual activity and primary thunderclap headache are self-limited diseases and the prognoses are good, but some patients with primary headache associated with sexual activity may have a prolonged course.

Sensitivity of the SNNOOP10 list in the high-risk secondary headache detection

AIM

To evaluate the diagnostic accuracy of the SNNOOP10 list in the detection of high-risk headaches.

METHODS

Patients that visited the Hospital Clínico San Carlos (Madrid) emergency department due to headache that were allocated to a Manchester Triage System level between critical and urgent were prospectively included but retrospectively analysed. A researcher blind to the patients' diagnosis administered a standardised questionnaire and afterwards a neurologist blind to the questionnaire results diagnosed the patient according to the International Classification of Headache Disorders. The primary endpoint was to assess the sensitivity of the SNNOOP10 list in the detection of high-risk headaches. Secondary endpoints included the evaluation of the sensitivity, specificity, positive predictive value, negative predictive value and area under the curve of each SNNOOP10 item.

RESULTS

Between April 2015 and October 2021, 100 patients were included. Patients were 44 years old (inter-quartile range: 33.6-64.7) and 57% were female. We identified 37 different diagnoses. Final diagnosis was a primary headache in 33%, secondary headache in 65% and cranial neuralgia in 2%. There were 46 patients that were considered as having high-risk headache. Patients from the primary headache group were younger and more frequently female. Sensitivity of SNNOOP10 list was 100% (95% confidence interval: 90.2%-100%). The items with higher sensitivity were neurologic deficit or disfunction (75.5%), pattern change or recent onset of the headache (64.4%), onset after 50 years (64.4%). The most specific items were posttraumatic onset of headache (94.5%), neoplasm in history (89.1%) and systemic symptoms (89%). The area under the curve of the SNNOOP10 list was 0.66 (95% CI: 0.55-0.76).

CONCLUSION

The red flags from the SNNOOP10 list showed a 100% sensitivity in the detection of high-risk headache disorders.

Neuroimaging of Headache: Indications and Controversies

Headache is a common presenting symptom in the ambulatory setting that often prompts imaging. The increased use and associated health care money spent in the setting of headache have raised questions about the cost-effectiveness of neuroimaging in this setting. Neuroimaging for headache in most cases is unlikely to reveal significant abnormality or impact patient management. In this article, reasons behind an observed increase in neuroimaging and its impact on health care expenditures are discussed. The typical imaging modalities available and various imaging guidelines for common clinical headache scenarios are presented, including recommendations from the American College of Radiology.

Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data

We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007−2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007−2010, 2011−2014, and 2015−2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007−2010 to 28.3% in 2015−2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015−2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007−2010 to 79.7% in 2015−2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.

Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study

BACKGROUND

Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation.

METHODS

This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test.

RESULTS

644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases-significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache.

CONCLUSIONS

Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.

Evaluating xanthochromia in the diagnosis of subarachnoid haemorrhage in Scotland in the Era of modern computed tomography

AIM

Cerebrospinal fluid (CSF) analysis for xanthochromia is routinely used to exclude subarachnoid haemorrhage (SAH). In this study, we evaluated the sensitivity and specificity of xanthochromia (by NEQAS-spectrophotometry) in routine clinical practice in three acute hospitals, in patients with suspected SAH. We explored whether including CSF red cell count (RCC) with xanthochromia improved diagnostic accuracy.

METHODS

In this retrospective analysis, all xanthochromia results were assessed over three consecutive years. Clinical information and Registry data were analysed to find all patients diagnosed with SAH. We correlated xanthochromia data with clinical and radiological findings.

RESULTS

There were 1761 xanthochromia performed. Of these, 26 (1.5%) were positive, 1624 (92%) negative and 72 (4.1%) were inconclusive. Of the 26 tests that were positive, 9 (35%) had confirmed SAH, 17 (65%) were falsely positive, with no false negative tests in our series. Xanthochromia identified 6% of all SAH diagnosed in the study. Incorporating RCC <1000 with xanthochromia, reducing false positive tests by 38% and inconclusive test by 85%.

CONCLUSION

The positive yield of xanthochromia is low but identified 6% of SAH. NEQAS-spectrophotometry is an excellent diagnostic method with 100% sensitivity, 99% specificity. Incorporating RCC markedly reduces false positive and inconclusive tests reducing need for further imaging.

Comparison of the efficacy of intranasal ketamine versus intravenous ketorolac on acute non-traumatic headaches: a randomized double-blind clinical trial

INTRODUCTION

Non - traumatic headaches are one of the most common causes of referral to hospital emergency. This study aimed to compare the efficacy of intranasal ketamine and intravenous ketorolac on acute non-traumatic headaches.

METHODS

This randomized and double-blind clinical trial was conducted in 2019. One hundred and forty samples were randomly divided into intranasal ketamine (A) and intravenous ketorolac (B). Group (A) received ketamine intranasal (0.75 mg/kg, max 75 mg), and group B received intravenous ketorolac (30 mg). Headache severity was measured on arrival, 30, 60, and 120 min after intervention with Visual Analogue Scale (VAS). The side effects were recorded an hour after the intervention.

RESULT

The mean difference of pain intensity 30, 60, and 120 min after the intervention between the two groups was statistically significant (p < 0.001). In the first 30 min, significant changes were observed in the VAS levels of the two groups. These changes were significantly greater in the intranasal ketamine group (p < 0.001). Side effects such as fatigue, dizziness, general discomfort, nausea, increased heart rate, and hypertension were significantly higher in the ketamine group (p < 0.05).

CONCLUSION

Intranasal ketamine and intravenous ketorolac both effectively reduced headaches. However, more analgesic effects of intranasal ketamine in a short time can be considered as a selective approach to reducing headaches.

TRIAL REGISTRATION

IRCT20180108038276N3 , Registered 29 September 2019.

ETHICS COMMITTEE REFERENCE NUMBER

IR.KUMS.REC.1398.068.

Cerebrovascular disease hospitalizations following emergency department headache visits: A nested case-control study

BACKGROUND

Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed.

METHODS

We conducted a nested case-control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1 year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t-test for continuous variables were used with statistical significance set at ≤0.05.

RESULTS

Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI] = 0.5-0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107 days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty-three cases and 53 matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p = 0.02) and neurosurgery (13.2% vs. 1.9%, p = 0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p = 0.03).

CONCLUSION

We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement.

Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study

OBJECTIVE

To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs).

BACKGROUND

Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally.

METHODS

An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome.

RESULTS

We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526).

CONCLUSION

Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

The Headache in Emergency Departments study: Opioid prescribing in patients presenting with headache. A multicenter, cross-sectional, observational study

OBJECTIVE

To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography.

BACKGROUND

International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice.

METHODS

This was a planned, multicenter, cross-sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator.

RESULTS

Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1-5.5), pre-ED opioid use (OR 1.42, 95% CI 1.11-1.82), and long-term opioid use (OR 1.80, 95% CI 1.26-2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3-11.0).

CONCLUSION

Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long-term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence-based interventions for headache.

BET 1: The Ottawa Subarachnoid Hemorrhage Clinical Decision Rule shows high sensitivity but limited evidence of patient benefit

A short-cut review of the literature was carried out to examine the diagnostic test characteristics and potential patient benefits through the use of the Ottawa Subarachnoid Haemorrhage Clinical Decision Rule. Nine papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that the Ottawa Clinical Decision Rule has a high sensitivity for the diagnosis of subarachnoid haemorrhage; however, there is limited robust evidence of international generalisability and no evidence of improved patient outcomes following implementation. Further prospective research is required in populations with variable prevalence to evaluate the safety and effectiveness of this intervention, compared with routine evaluation strategies.

Headache Emergencies

Headache is a common reason for seeking medical attention. Most cases are benign primary headache disorders; however, there is significant overlap between symptoms of these disorders and secondary headaches. Differentiating these clinical scenarios requires a careful history with attention to red flag symptoms and a neurologic examination. These details can identify dangerous disorders: subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, elevated intracranial pressure, hydrocephalus, cerebral venous sinus thrombosis, arterial dissection, central nervous system infection, and inflammatory vasculitis. Older, pregnant, or immunocompromised patients have a higher risk for secondary disorders; clinicians should have a different threshold to conduct evaluations in such patients.

Subarachnoid hemorrhage in the emergency department

BACKGROUND

Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician.

DISCUSSION

The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest.

CONCLUSION

Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.

Is a Lumbar Puncture Required to Rule Out Atraumatic Subarachnoid Hemorrhage in Emergency Department Patients With Headache and Normal Brain Computed Tomography More Than Six Hours After Symptom Onset?

BACKGROUND

Atraumatic subarachnoid hemorrhage (SAH) is a deadly condition that most commonly presents as acute, severe headache. Controversy exists concerning evaluation of SAH based on the time from onset of symptoms, specifically if the headache occurred > 6 h prior to patient presentation.

CLINICAL QUESTION

Do patients undergoing evaluation for atraumatic SAH who have a negative computed tomography (CT) scan of the head obtained more than 6 h after symptom onset require a subsequent lumbar puncture to rule out the diagnosis?

EVIDENCE REVIEW

Studies retrieved included a retrospective cohort study, two prospective cohort studies, and a case-control study. These studies provide estimates of the diagnostic accuracy of head CT imaging obtained > 6 h from symptom onset and diagnostic test characteristics of subsequent lumbar puncture.

CONCLUSION

The probability of SAH above which emergency clinicians should perform a lumbar puncture is 1.0%. This threshold is essentially the same as the estimated probability of SAH in patients with a negative head CT obtained more than 6 h from symptom onset. Emergency physicians might reasonably decide to either perform or forego this procedure. Consequently, we contend that the decision whether to perform lumbar puncture in these instances is an excellent candidate for shared decision-making.

Temporal distribution of emergency room visits in patients with migraine and other headaches

Background: Headache is a leading reason for presentation to the emergency department (ED) with migraine being the most frequently headache. To ensure the adequate staffing of healthcare providers during peak times of headache visits, we analyzed the temporal distribution of emergency department visits in patients presenting with headache and/or migraine.Research design and methods: The authors conducted an ecological study, including all consecutive visits to the ED for headache. Patients were classified according to the IHS Classification. We analyzed circadian, circaseptan and circannual patterns for number of visits, comparing migraine patients with other headache patients.Results: There were 2132 ED visits for headache, including primary headache in 1367 (64.1%) cases; migraine in 963 (45.2%); secondary headache in 404 (18.9%); and unspecified headache in 366 (17.1%). The circadian pattern showed peaks around 11:00-13:00 and 17:00-19:00, with visits during the night shift 45% less frequent (p < 0.001). The circaseptan pattern showed a peak on Monday-Tuesday and a low point on Sunday (p < 0.007). The circannual pattern peaked in March and decreased in June.Conclusions: ED visits for headache showed specific circadian, circaseptan and circannual variations. No differences were found in these patterns when comparing migraine patients to other headache patients.

Evaluating thunderclap headache

PURPOSE OF REVIEW

Thunderclap headache (TCH) is an abrupt-onset of severe headache that needs to be thoroughly investigated because the most common secondary cause is subarachnoid hemorrhage (SAH). There has been no consensus guideline regarding the diagnostic workup. This review aims to provide an update on the evaluation of TCH.

RECENT FINDINGS

The most important update in the 2019 American College of Emergency Physicians guideline for evaluation of acute headache in the emergency department is that negative noncontrast brain computed tomography (CT) findings within 6 h from ictus essentially excludes SAH. Additionally, the updated guideline recommends that after a negative brain CT, CT angiogram is a reasonable alternative to lumbar puncture if clinical suspicion of an intracranial source of SAH is high. An important update of reversible vasoconstriction syndrome (RCVS), the second most common etiology of TCH, is the RCVS2 score development based on clinical and radiological features, providing high specificity and sensitivity for distinguishing RCVS from other intracranial arteriopathies.

SUMMARY

Although the evaluation of TCH is exhaustive, the potentially catastrophic consequence of a missed diagnosis of sentinel headache justifies the efforts. Awareness of the clinical features and application of diagnostic tools specific for different pathological conditions can facilitate the diagnostic workup.

Management of thunderclap headache in the emergency room: A retrospective cohort study

INTRODUCTION

The evaluation of red flags is crucial for the accurate the diagnosis of headache disorders, especially for thunderclap headache. We analysed if secondary headache disorders were adequately ruled out in patients that presented to the emergency room with thunderclap headache.

METHODS

In this retrospective cohort study, we screened all patients that visited the emergency room for headache, including those that described thunderclap headache. We measured the frequency with which secondary causes were not adequately ruled out. We analysed the order of the exams, the final diagnosis, and the time elapsed between arrival, initial request for imaging, and the completion of the imaging.

RESULTS

We screened 2132 patients, and 42 (1.9%) fulfilled eligibility criteria. Mean age was 43.1 ± 17.1 years, and 57% of patients were female. For 22 (52.4%) patients, the work-up was incomplete. Vascular study was missing in 16 (38.1%) patients, cerebrospinal fluid evaluation in nine (21.4%), and magnetic resonance imaging in seven (16.7%), with multiple assessments missing in six (14.3%). There were ten different combinations in which the exams were performed, with the most frequent being the second exam's cerebral spinal fluid evaluation in 18 (52.9%) and the computed tomography angiogram in 10 (29.4%). A secondary cause of thunderclap headache was found in 16 (38.1%) patients, and four (9.5%) had a primary headache diagnosis after an adequate and complete study.

CONCLUSIONS

Thunderclap onset was described in one of every 50 patients that visited the emergency room for headache. More than half of these patients were not adequately managed. More than a third of thunderclap headache patients had a secondary cause.

Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes, An Update

In the initial assessment of the headache patient, the emergency physician must consider several dangerous secondary causes of headache. A thorough history and physical examination, along with consideration of a comprehensive differential diagnosis may alert the emergency physician to the diagnosis of a secondary headache particularly when the history is accompanied by any of the following clinical features: sudden/severe onset, focal neurologic deficits, altered mental status, advanced age, active or recent pregnancy, coagulopathy, malignancy, fever, visual deficits, and/or loss of consciousness.

Spectrophotometry of cerebrospinal fluid for xanthochromia is a sensitive and specific test for subarachnoid bleeding but adds little to computed tomography

Subarachnoid hemorrhage (SAH) is a serious neurological event associated with high morbidity and mortality. Computed tomography of the cerebrum (CTC) is the diagnostic method of choice, but in case of negative CTC but strong suspicion of SAH, lumbar puncture with spectrophotometric analysis of cerebrospinal fluid (CSF) for xanthochromia is performed. We wanted to examine the diagnostic properties of CSF spectrophotometry for xanthochromia testing. We performed a retrospective study of the diagnostic properties of CSF analysis for xanthochromia using spectrophotometry in the diagnosis of SAH. A total of 489 CSF samples were analyzed for xanthochromia, according to international guidelines, from 2009 until 2014 and for 411 of these the patient files were retrieved and examined for final clinical diagnosis and result of CTC. One patient with SAH did not have a positive spectrophotometry report and another patient with SAH had an equivocal report. In four patients did initial CTC not correctly identify SAH. For patients with a negative CTC within six hours of symptom onset spectrophotometry for xanthochromia in the CSF had a diagnostic sensitivity of 100% and a diagnostic specificity of 98.5%. The positive predictive value was 16.7% and the negative predictive value 100%. We conclude that spectrophotometry of CSF for xanthochromia is a sensitive and specific test for diagnosing SAH. However, it seems that an initial CTC identifies almost all patients with SAH. This suggests that in our and similar diagnostic settings, lumbar puncture and testing for xanthochromia might only be relevant in very few cases, if not obsolete.

Phenotypic characterization of acute headache attributed to SARS-CoV-2: An ICHD-3 validation study on 106 hospitalized patients

Introduction

Headache is a common symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we aimed to characterize the phenotype of headache attributed to SARS-CoV-2 infection and to test the International Classification of Headache Disorders (ICHD-3) phenotypic criteria for migraine and tension-type headache.

Methods

The study design was a cross-sectional study nested in a cohort. We screened all consecutive patients that were hospitalized and had a positive SARS-CoV-2 test. We included patients that described headache if the headache was not better explained by another ICHD-3 diagnosis. Patients were interviewed by two neurologists.

Results

We screened 580 patients and included 130 (mean age 56 years, 64% female). Headache was the first symptom of the infection in 26% of patients and appeared within 24 hours in 62% of patients. The headache was bilateral in 85%, frontal in 83%, and with pressing quality in 75% of patients. Mean intensity was 7.1, being severe in 64%. Hypersensitivity to stimuli occurred in 57% of patients. ICHD-3 criteria for headache attributed to systemic viral infection were fulfilled by 94% of patients; phenotypic criteria for migraine were fulfilled by 25% of patients, and tension-type headache criteria by 54% of patients.

Conclusion

Headache attributed to SARS-CoV-2 infection in hospitalized patients has severe intensity, frontal predominance and oppressive quality. It occurs early in the course of the disease. Most patients fulfilled ICHD-3 criteria for headache attributed to systemic viral infection; however, the phenotype might resemble migraine in a quarter of cases and tension-type headache in half of the patients.

Diagnosis and Initial Emergency Department Management of Subarachnoid Hemorrhage

Atraumatic subarachnoid hemorrhage represents a small proportion of strokes, but is a true medical emergency that results in significant morbidity and mortality. Making the diagnosis can be challenging and misdiagnosis can result in devastating consequences. There are several time-dependent diagnostic and management considerations for emergency physicians and other frontline providers. This article reviews the most up-to-date literature on the diagnostic workup of subarachnoid hemorrhage, avoiding misdiagnosis, and initial emergency department management recommendations.

Study about the Manchester Triage System subtriage in patients that visited the Emergency Department due to headache

INTRODUCTION

Headache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the Emergency Department due to headache.

MATERIAL AND METHODS

We studied a series of consecutive patients who came to the Emergency Department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned.

RESULTS

We registered a total of 1,120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, two patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and five as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level.

CONCLUSION

During the study period, at least one in 10 patients attending the Emergency Department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

Ambulatory Follow-up and Outcomes Among Medicare Beneficiaries After Emergency Department Discharge

IMPORTANCE

Ambulatory follow-up care is frequently recommended after an emergency department (ED) visit. However, the frequency with which follow-up actually occurs and the degree to which follow-up is associated with postdischarge outcomes is unknown.

OBJECTIVES

To examine the frequency and variation in ambulatory follow-up among Medicare beneficiaries discharged from US EDs and the association between ambulatory follow-up and postdischarge outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 9 470 626 ED visits to 4728 US EDs among Medicare beneficiaries aged 65 and older from 2011 to 2016 who survived the ED visit and were discharged to home used Kaplan-Meier curves and proportional hazards regression. Data analysis was conducted from December 2019 to July 2020.

EXPOSURES

Ambulatory follow-up after discharge from the ED.

MAIN OUTCOMES AND MEASURES

Postdischarge mortality, subsequent ED visit, or inpatient hospitalization within 30 days of an index ED visit.

RESULTS

The study sample consisted of 9 470 626 index outpatient ED visits to 4684 EDs; most visits (5 776 501 [61.0%]) were among women, and the mean (SD) age of patients was 77.3 (8.4) years. In this sample, the cumulative incidence of ambulatory follow-up was 40.5% (3 822 133 patients) at 7 days and 70.8% (6 662 525 patients) at 30 days, after accounting for censoring and for mortality as a competing risk. Characteristics associated with lower rates of ambulatory follow-up included beneficiary Medicaid eligibility (hazard ratio [HR], 0.77; 95% CI, 0.77-0.78; P < .001), Black race (HR, 0.82; 95% CI, 0.81-0.83; P < .001), and treatment at a rural ED (HR, 0.75; 95% CI, 0.73-0.77; P < .001) in the multivariable regression model. Ambulatory follow-up was associated with lower risk of postdischarge mortality (HR, 0.49; 95% CI, 0.49-0.50; P < .001) but higher risk of subsequent inpatient hospitalization (HR, 1.22; 95% CI, 1.21-1.23; P < .001) and ED visits (HR, 1.01; 95% CI, 1.00-1.01; P < .001), adjusting for visit diagnosis, patient demographic characteristics, and chronic conditions.

CONCLUSIONS AND RELEVANCE

In this cohort study of Medicare beneficiaries discharged from the ED, nearly 30% lacked ambulatory follow-up at 30 days, with variation in follow-up rates by patient and hospital characteristics. Having an ambulatory follow-up visit was associated with higher risk of subsequent hospitalization but lower risk of mortality. Ambulatory care access may be an important driver of clinical outcomes after an ED visit.

Frequency and Type of Red Flags in Patients With Covid-19 and Headache: A Series of 104 Hospitalized Patients

OBJECTIVE

In this study, we aimed to evaluate the frequency of the main red flags in patients with headache who do have Covid-19.

BACKGROUND

Headache is one of the most frequent neurologic symptoms of Coronavirus disease 2019 (Covid-19). Diagnosis of secondary headache disorders is still based on the presence of red flags.

DESIGN AND METHODS

Cross-sectional study of hospitalized patients with confirmed Covid-19 disease. We interrogated every patient about the presence of headache and if so, a headache expert conducted a structured interview assessing the presence and type of the main red flags. We evaluated the presence of laboratory abnormalities on admission.

RESULTS

We screened 576 consecutive patients, 130/576 (22.6%) described headache, and 104 were included in the study. Mean age of patients was 56.7 (standard deviation: 11.2) and 66/104 (63.4%) were female. Red flags concerning prior medical history were present in 79/104 (76.0%) cases, and those related to the headache itself were observed in 99/104 (95.2%) patients. All patients 104/104 (100%) described systemic symptoms and 86/104 (82.7%) some neurologic symptoms. Laboratory results were abnormal in 98/104 (94.2%) cases. The most frequent red flags were fever, in 93/104 (89.4%) patients, cough, in 89/104 (85.6% cases), and increased C-reactive protein in 84/100 (84.0%) cases.

CONCLUSION

In patients with Covid-19 that described the headache red flags were present in most cases. There was not any universal red flag, being necessary the comprehensive evaluation of all of them.

Nontraumatic Headache in Adult Emergency Patients: Prevalence, Etiologies, and Radiological Findings

The aim of this study was to measure prevalence, to describe underlying etiologies, and to assess radiological findings, focusing on significant intracranial abnormality (sICA). This was a prospective study of unselected adult patients admitted to the emergency department (ED) in a tertiary care hospital where all presenters were systematically interviewed about their symptoms. We attributed nontraumatic headache with neuroimaging to four groups: Normal or no new finding, extracranial abnormality, insignificant intracranial abnormality, or significant intracranial abnormality. sICA was defined as “needing acute therapy”, “needing follow-up neuroimaging”, or “clinically important neurological disorder”. Among 11,269 screened ED presentations, the prevalence of nontraumatic headache was 10.1% (1132 patients). Neuroimaging (cCT and/or cMRI) was performed in 303 patients. Seventy (23.1% of scanned; 6.2% of all headache patients) patients had sICA. Etiologies were cerebrovascular disease (56%), intracranial bleeding (17%), tumors (14%), infection (9%), and others (6%). Short-term outcome was excellent, with 99.3% in-hospital survival in patients with and 99.4% in patients without neuroimaging, and 97.1% in sICA; 1-year survival in outpatients with neuroimaging was 99.2%, 99.0% in outpatients without, and 88.6% in patients with sICA. Factors associated with sICA were age, emergency severity index (ESI) of 1 or 2, Glasgow coma score (GCS) under 14, focal neurological signs, and a history of malignancy. Prevalence of headache and incidence of sICA were high, but survival after work-up for nontraumatic headache was excellent in the 94% patients without sICA. Due to the incidence of sICA, extensive indication for neuroimaging in headache patients is further warranted, particularly in patients with risk factors.

Out-of-hospital assessment and treatment of adults with atraumatic headache

OBJECTIVE

Little is known about the presentation or management of patients with headache in the out-of-hospital setting. Our primary objective is to describe the out-of-hospital assessment and treatment of adults with benign headache. We also describe meaningful pain reduction stratified by commonly administered medications.

METHODS

This retrospective evaluation was conducted using data from a large national cohort. We included all 911 responses by paramedics for patients 18 and older with headache. We excluded patients with trauma, fever, suspected alcohol/drug use, or who received medications suggestive of an alternate condition. We presented our findings with descriptive statistics.

RESULTS

Of the 5,977,612 emergency responses, 1.1% (66,235) had a provider-documented primary impression of headache or migraine and 52.5% (34,763) met inclusion criteria. An initial pain score was recorded for 73.5% (25,544) of patients, and 58.5% (14,948) of these patients had multiple pain scores documented. Of the patients with multiple pain scores documented, 53.8% (8037) of patients had an initial pain score >5. Of these, 7.1% (573) were administered any medication. Among patients receiving a single medication, Fentanyl was the most commonly administered (32.1%, 126). As a group, opioids were the most commonly administered class of drugs (38.9%, 153) and were associated with the largest proportion of clinically significant pain reduction (69.3%, 106). Dopamine antagonists were given least frequently (9.9%, 39) but had the second largest proportion of pain reduction (43.6%, 17).

CONCLUSION

Out-of-hospital pain scores were documented infrequently and less than one in five patients with initial pain scores >5 received medication. Additionally, adherence to evidence-based guidelines was infrequent.

ACEP Guidelines on Acute Nontraumatic Headache Diagnosis and Management in the Emergency Department, Commentary on Behalf of the Refractory, Inpatient, Emergency Care Section of the American Headache Society

The American College of Emergency Physicians (ACEP) published guidelines in July 2019 on the diagnosis and management of acute nontraumatic headaches in the emergency department, focusing predominantly on the diagnosis of subarachnoid hemorrhage and the role of imaging and lumbar puncture in diagnosis. The ACEP Clinical Policies document is intended to aide Emergency Physicians in their approach to patients presenting with acute headache and to improve the accuracy of diagnosis, while promoting safe patient care practices. The Clinical Policies document also highlights the need for future research into best practices to distinguish primary from secondary headaches and the efficacy and safety of current treatment options for acute headaches. The following commentary on these guidelines is intended to support and expand on these guidelines from the Headache specialists' perspective, written on behalf of the Refractory, Inpatient, Emergency Care section of the American Headache Society (AHS). The commentary have been reviewed and approved by Board of Directors of the AHS.