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Headache

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

Scope of Application

This guideline is intended for physicians working in emergency departments who are evaluating nontraumatic patients with acute onset headache and nonfocal neurologic examination findings.

Inclusion Criteria

This guideline is intended for acute adult nontraumatic headaches.

Exclusion Criteria

This guideline is not intended for patients with chronic headaches or pediatric, pregnant, or trauma patients.

Critical Questions

  • In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    Use the Ottawa Subarachnoid Hemorrhage Rule (>40 years, complaint of neck pain or stiffness, witnessed loss of consciousness, onset with exertion, thunderclap headache, and limited neck flexion on examination) as a decision rule that has high sensitivity to rule out subarachnoid hemorrhage, but low specificity to rule in subarachnoid hemorrhage, for patients presenting to the emergency department with a normal neurologic examination result and peak headache severity within 1 hour of onset of pain symptoms.  

    Although the presence of neck pain and stiffness on physical examination in emergency department patients with an acute headache is strongly associated with subarachnoid hemorrhage, do not use a single physical sign and/or symptom to rule out subarachnoid hemorrhage.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    Use the Ottawa Subarachnoid Hemorrhage Rule (>40 years, complaint of neck pain or stiffness, witnessed loss of consciousness, onset with exertion, thunderclap headache, and limited neck flexion on examination) as a decision rule that has high sensitivity to rule out subarachnoid hemorrhage, but low specificity to rule in subarachnoid hemorrhage, for patients presenting to the emergency department with a normal neurologic examination result and peak headache severity within 1 hour of onset of pain symptoms.  

    Although the presence of neck pain and stiffness on physical examination in emergency department patients with an acute headache is strongly associated with subarachnoid hemorrhage, do not use a single physical sign and/or symptom to rule out subarachnoid hemorrhage.

    Level C Recommendations

    None specified.

  • In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications?

    Recommendations
    Level A Recommendations

    Preferentially use nonopioid medications in the treatment of acute primary headaches in emergency department patients.

    Level B Recommendations

    None specified.

    Level C Recommendations

    None specified.

    Level A Recommendations

    Preferentially use nonopioid medications in the treatment of acute primary headaches in emergency department patients.

    Level B Recommendations

    None specified.

    Level C Recommendations

    None specified.

  • In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    Use a normal noncontrast head computed tomography* performed within 6 hours of symptom onset in an emergency department headache patient with a normal neurologic examination, to rule out nontraumatic subarachnoid hemorrhage.

    *Minimum third-generation scanner.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    Use a normal noncontrast head computed tomography* performed within 6 hours of symptom onset in an emergency department headache patient with a normal neurologic examination, to rule out nontraumatic subarachnoid hemorrhage.

    *Minimum third-generation scanner.

    Level C Recommendations

    None specified.

  • In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations

    Perform lumbar puncture or computed tomography angiography to safely rule out subarachnoid hemorrhage in the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography result.

    Use shared decision making to select the best modality for each patient after weighing the potential for false-positive imaging and the pros and cons associated with lumbar puncture.

    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations

    Perform lumbar puncture or computed tomography angiography to safely rule out subarachnoid hemorrhage in the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography result.

    Use shared decision making to select the best modality for each patient after weighing the potential for false-positive imaging and the pros and cons associated with lumbar puncture.

Download the Policy

PDF Icon cp-headache.pdf July 2019

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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