Evaluation and Management of Life-Threatening Headaches in the Emergency Department -
Publication Date: February 2019 (Volume 21, Number 2)
No CME for this activity
David Zodda, MD, FACEP
Assistant Program Director, Emergency Medicine Residency, Hackensack University Medical and Trauma Center; Assistant Professor, Department of Emergency Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ
Gabrielle Procopio, PharmD, BCPS
Emergency Medicine Clinical Pharmacist, Department of Pharmacy, Hackensack University Medical and Trauma Center; Assistant Professor, Department of Emergency Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ
Amit Gupta, MD
Assistant Program Director, Emergency Medicine Residency, Hackensack University Medical and Trauma Center; Assistant Professor, Department of Emergency Medicine, Hackensack Meridian School of Medicine at Seton Hall Medical School, Hackensack, NJ
Mert Erogul, MD
Attending Physician, Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, NY
Steven A. Godwin, MD, FACEP
Professor and Chair, Department of Emergency Medicine; Assistant Dean, Simulation Education, University of Florida College of Medicine- Jacksonville, Jacksonville, FL
Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches --migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening. This issue details the important pathophysiologic features of the most common types of life-threatening headaches, the key historical and physical examination information emergency clinicians must obtain, the red flags that cannot be missed, and the current evidence for best-practice testing, imaging, treatment, and disposition.
Excerpt From This Issue
A previously healthy 30-year-old man presents to the ED complaining of the “worst headache of my life.” He describes it as sharp, nonradiating, with an abrupt onset 5 hours ago. You are concerned for subarachnoid hemorrhage. You provide pain medication and obtain a noncontrast CT scan of the head, which is negative. The patient is feeling better and wants to go home. You wonder whether a negative CT is sufficient to rule out an SAH or whether a lumbar puncture should be done...
A 55-year-old man with history of nonsmall cell lung cancer who is on cisplatin presents with an acute headache and lethargy for 6 hours. His vital signs are remarkable for a blood pressure of 210/120 mm Hg, heart rate of 70 beats/min, and a temperature of 36.7°C (98°F). His physical exam reveals a lethargic patient with no localizing neurologic signs and no meningismus. You order a noncontrast CT of the head and consider lowering this patient’s blood pressure, though you wonder how much and how fast it should be reduced...
I appreciate the great review of secondary headache disorders. Cardinal features, with included likelihood ratios when appropriate, are useful. David B, MD - 10/09/2020
Great refresher for headaches with pregnancy. Michael M, PA-C - 09/09/2020
I feel more comfortable with non con head CT in the first six hours with SAH rule out. Sara B, MD - 09/03/2020
Excellent evidence based data and presentations. Keep up the fantastic and timely work. Kent S, PA-C - 08/12/2020
After participating in this course, I will use D-dimer for low-risk patients suspected of CVT, and will look for beading of temporal artery on patients suspected of having GCA given the high LR of this clinical exam finding. Nathan W - 07/31/2020
This clinical data on diagnostic criteria for the differential helps me guide my practice for my patients. Bret P, MD - 07/16/2020
This broadened my consideration of other causes of headache, like IIHS. June M, MD - 07/02/2020
Great red flag checklist for headache. Kasia M, MD - 06/17/2020
I feel more confident in SAH and pre-eclampsia and GCA workups. William F, DO - 05/26/2020
I now have a better assessment, evaluation, and treatment for patients with headache. James K, MD - 05/14/2020
A very good discussion of the evaluation and management of life threatening headaches in the ER. Michael K, MD - 05/08/2020
I’ll now have better risk stratification decisions and discussions with patients. Jason D., MD - 04/09/2019
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