Pain management/clinical policy
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache

https://doi.org/10.1016/j.annemergmed.2008.07.001Get rights and content

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Abstract

This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache

Methodology

This clinical policy was created after careful review and critical analysis of the medical literature. Multiple searches of MEDLINE and the Cochrane database were performed. Specific key word/phrases used in the searches are identified under each critical question. To update the 2002 ACEP policy, which used literature up to December 1999, all searches were limited to English-language sources, human studies, adults, and years January 2000 to August 2006. Additional articles were reviewed from

Level A recommendations

None specified.

Level B recommendations

None specified.

Level C recommendations

Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.

Key words/phrases for literature searches: thunderclap headache, acute headache, response to therapy, cause or etiology, and variations and combinations of the key words/phrases.

Because headache is a common complaint, physicians have sought ways to differentiate the serious life-, limb-, vision-, or brain-threatening etiologies from the more

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References (91)

  • J. van Gijn et al.

    Subarachnoid haemorrhage

    Lancet

    (2007)
  • J.A. Edlow et al.

    Aneurysmal subarachnoid hemorrhage: update for emergency physicians

    J Emerg Med

    (2008)
  • R.W. Evans

    Complications of lumbar puncture

    Neurol Clin

    (1998)
  • J.J. Perry et al.

    Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage?

    Ann Emerg Med

    (2008)
  • B.M. Boesiger et al.

    Subarachnoid hemorrhage diagnosis by computed tomography and lumbar puncture: are fifth generation CT scanners better at identifying subarachnoid hemorrhage?

    J Emerg Med

    (2005)
  • R.L. Byyny et al.

    Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage

    Ann Emerg Med

    (2008)
  • M.K. Lashutka et al.

    The relation of intracranial pressure to intraocular pressure

    Ann Emerg Med

    (2004)
  • A. Field et al.

    Evaluation of the patient with nontraumatic headache: an evidence-based approach

    Emerg Med Clin North Am

    (1999)
  • T.F. Witham et al.

    Unruptured cerebral aneurysm producing a thunderclap headache

    Am J Emerg Med

    (2000)
  • J.N. Goldstein et al.

    Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses

    Cephalalgia

    (2006)
  • Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache

    Ann Emerg Med

    (2002)
  • J.J. Perry et al.

    Attitudes and judgment of emergency physicians in the management of patients with acute headache

    Acad Emerg Med

    (2005)
  • S. Diamond

    Head pain: diagnosis and management

    Clin Symp

    (1994)
  • M.A. Moskowitz

    Neurogenic inflammation in the pathophysiology and treatment of migraine

    Neurology

    (1993)
  • J.W. Lance

    Current concepts of migraine pathogenesis

    Neurology

    (1993)
  • S.J. Peroutka

    5-Hydroxytryptamine receptor subtypes and the pharmacology of migraine

    Neurology

    (1993)
  • Evidence-based treatment guidelines for migraine headache in the primary care setting: pharmacological management of acute attacksAmerican Academy of Neurology, 2000

  • D.W. Gross et al.

    Dihydroergotamine and metoclopramide in the treatment of organic headache

    Headache

    (1995)
  • R.B. Lipton et al.

    Sumatriptan relieves migraine-like headaches associated with carbon monoxide exposure

    Headache

    (1997)
  • E. Agostoni

    Headache in cerebral venous thrombosis

    Neurol Sci

    (2004)
  • E.C. Leira et al.

    Sumatriptan can alleviate headaches due to carotid artery dissection

    Headache

    (2001)
  • K. Pfadenhauer et al.

    The risks of sumatriptan administration in patients with unrecognized subarachnoid haemorrhage (SAH)

    Cephalalgia

    (2006)
  • J. Rothrock

    The perils of misinterpreting a treatment response

    Headache

    (2005)
  • K.-C. Wang et al.

    Headache profiles in patients with a dilatated cyst of the cavum septi pellucidi

    Cephalalgia

    (2004)
  • Practice parameter: neuroimaging in the patient presenting with seizure

    Ann Emerg Med

    (1996)
  • R. Fitzpatrick et al.

    Referrals to neurologists for headaches not due to structural disease

    J Neurol Neurosurg Psychiatry

    (1981)
  • Practice parameter: the utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations

    Neurology

    (1994)
  • Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headacheAmerican Academy of Neurology, 2000

  • Clinical policy for the initial approach to adolescents and adults presenting to the emergency department with a chief complaint of headache

    Ann Emerg Med

    (1996)
  • A. Lledo et al.

    Acute headache of recent onset and subarachnoid hemorrhage: a prospective study

    Headache

    (1994)
  • D.W. Harling et al.

    Thunderclap headache: is it migraine?

    Cephalalgia

    (1989)
  • S. Akpek et al.

    Cost-effectiveness of computed tomography in the evaluation of patients with headache

    Headache

    (1995)
  • P. Demaerel et al.

    The role of cranial computed tomography in the diagnostic work-up of headache

    Headache

    (1996)
  • C.S. Mitchell et al.

    Computed tomography in the headache patient: is routine evaluation really necessary?

    Headache

    (1993)
  • M. Ramirez-Lassepas et al.

    Predictors of intracranial pathologic findings in patients who seek emergency care because of headache

    Arch Neurol

    (1997)
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    Approved by the ACEP Board of Directors, June 24, 2008

    Supported by the Emergency Nurses Association, July 29, 2008

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