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

Points and Pearls Excerpt

• The most common life-threatening causes of headaches are subarachnoid hemorrhage (SAH), cervical artery dissection (CAD), cerebral venous thrombosis (CVT), idiopathic intracranial hypertension (IIH), giant cell arteritis (GCA), and posterior reversible encephalopathy syndrome (PRES), and pre-eclampsia.
• SAH is commonly caused by aneurysm rupture; 75% present with abrupt onset. Administer nimodipine in aneurysmal SAH to improve outcomes. The use of prophylactic antiepileptic drugs is controversial.
• CAD is commonly associated with trauma and connective tissue disorders. Treat extracranial dissections with IV heparin followed by warfarin or a direct oral anticoagulant. Treat intracranial dissections with aspirin or clopidogrel.
• CVT presents as a gradual-onset headache that is often the result of thrombotic disease and spreading facial infections. Treat with low-molecular weight heparin or heparin bridge to warfarin. Consider broad-spectrum antibiotics if an infectious etiology is suspected.

Most Important References

• Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1- 211. (Clinical guideline) 
• Edlow JA, Panagos PD, Godwin SA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407-436. (Clinical policy)
• Carpenter 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;23(9):963- 1003. (Meta-analysis; 22 studies) 
• Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of head-ache for diagnosis of subarachnoid hemorrhage: prospective cohort study. BMJ. 2011;343:d4277. (Prospective; 3132 patients)
• Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365. (Prospective; 2794 patients)
• ACOG Task Force on Hypertension and Pregnancy. Hypertension in pregnancy. American College of Obstetricians and Gynecologists. Accessed January 10, 2019. (Expert/ guideline recommendations)