Headache in the Emergency Department

Headache in the Emergency Department – A real headache for Emergency Physicians – Podcast

We’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 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

Test Your Learning!

Which headaches do I need to worry about?

• 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

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]

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]

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]

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