I Can’t Get You Out of my Head – Headache at St Emlyns

HORIZONSWe’ve all had headaches, but not often severe enough to prompt us to seek help in an Emergency Department.

Many patients presenting to the ED with a primary presenting of feature of headache will have serious pathology. In Virchester audits the number with serious disease (tumour, bleeding, meningitis etc.) has remained at about 10% for many years. Our job as emergency physicians is to identify those with life threatening disease and also to help those with lesser disease burden, but who may still require care. Key to this is actively ruling out the life-threatening and life-changing diagnoses:

  • Subarachnoid Haemorrhage
  • Meningitis
  • Tumours and Space Occupying Lesions
  • Temporal Arteritis

Listen to Simon and Iain discuss how to approach these patients here

 

More here from the superb Sarah Robinson reiterating some of the key points.

Test Your Learning!

[DDET Which headaches do I need to worry about?]

Headache Red Flags + Logo

 

Sudden onset headache (classically patients who feel as though they’ve been hit on the back of the head) or onset during exercise

First and worst – headache in patients who don’t have frequent headaches or migraines and severe headache particularly if described as “the worst headache of my life”

Headaches in the context of fever or seizure

Occipital headache

Headaches which are worse during exercise or present on waking

[/DDET]

[DDET How else should I assess these patients?]

A thorough examination including a neurological exam which is clearly documented is essential here – and remember some patients with serious underlying causes may have subtle defects that they can describe but which you might not be able to elicit on examination – this doesn’t mean they are making it up! [/DDET]

[DDET Who should I be thinking about CT scans for?]

Patients with concerning headache features are worth speaking to a senior doctor about. Deciding not to CT these patients is a tricky decision and we should expect the majority of these scans to be normal (that doesn’t mean it shouldn’t have been performed!) so in the presence of any red flag features definitely discuss with a senior about a scan – and if you are concerned about other patients they should be discussed too.[/DDET]

[DDET What other tests might help me here?]

Lumbar puncture is pretty controversial – and not a decision you are going to make without senior input!

Blood tests probably aren’t going to be that useful unless you think the patient might have temporal arteritis in which case elevated inflammatory markers. [/DDET]

[DDET What if I think the patient might have meningitis?]

Don’t be reassured by normal blood tests – in fact, if you think it might be meningitis you shouldn’t be waiting for blood results at all. Early antibiotics save lives so if you are concerned enough to be considering antibiotics then it’s better to give the antibiotics – don’t be the doctor who writes “?meningitis” in the notes and does nothing else! As ever, if you’re concerned your seniors are there to help.[/DDET]

Further Resources

Headaches at Life in the Fast Lane – a great summary from the LiTFL crew

NICE Guidelines (NCG150) – diagnosis and management of headaches; there’s a flowchart and some red flags although you could read the St Emlyn’s summary here!

Headache from the Flipped EM Classroom

Posted by Iain Beardsell

Dr Iain Beardsell. MBChB (Birm) FRCEM is section lead for podcasts. Editorial Board Member St Emlyn’s blog and podcast. He is a Consultant in Emergency Medicine at University Hospital Southampton and a Consultant in Pre Hospital Emergency Medicine. Iain qualified in 1998 and over the past 20 years has trained and practiced medicine in major teaching hospitals both in the UK and overseas. He has been a consultant at University Hospital Southampton for the past ten years, including a three year term as the unit’s Clinical Director. UHS is the main Major Trauma Centre for the South Coast region of England as well as the eighth largest hospital in the UK. Iain is also a highly regarded advisor to television medical dramas, including Casualty and Good Karma Hospital. An acclaimed speaker, Iain has spoken at international conferences in Australia, Ireland, Austria and Germany as well as across the UK. You will find him on twitter as @docib

  1. On headache, we should explode the myth that raised ICP is a specific contraindication to LP because the patients might “cone”. Evidence well presented here: http://crashingpatient.com/medical-surgical/herniation-lumbar-puncture%C2%A0.htm/

    Reply

    1. Good point Jo. That’s going to be a tough one to crack in Virchester as it is fairly embedded in some minds (maybe we need to scan them for a #dogma centre).

      In fairness our radiologists are quite clear about this, but some clinical teams are still firmly in belief of LP=need for preCT

      Our work will never be done 🙂

      S

      Reply

  2. […] for the first time in elderly patients – in particular “migraine” (could this headache be a cerebral bleeding event?), “renal colic” (think AAA!) and […]

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  3. […] and are covered well and hammered into our heads.  For FOAM core content on this, check out the St. Emlyn’s podcast.  On this episode, we’re running a mini-ophthalmology headache special and focusing on […]

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  4. If a CT scan is done for a suspected SAH, and it is negative, how soon afterwards can you do an LP? I have read that you must wait at least 12 hours?
    How useful is an MRI brain for SAH?

    Reply

  5. […] in fact, that it has two curriculum sections of its own (and we’ve already produced an induction post about headaches that you can find here). It can be tricky to find the risk/benefit balance for these patients given the host of possible […]

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Thanks so much for following. Viva la #FOAMed

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