Evaluation and Management of Life-Threatening Headaches in the Emergency Department -

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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

 

Abstract

 

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...