1. ACEP Clinical Policy: Adult Headache Patients

2. Ponte Vedra Beach, FL June 24, 2010 2010 Clinical Decision Making in Emergency Medicine Ponte Vedra Beach, FL June 24, 2010

3. Edward P. Sloan, MD, MPH FACEP Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL

4. Attending Physician Emergency Medicine University of Illinois Hospital Swedish American Belvidere Hospital Chicago, IL

5. Disclosures FERNE Chairman and President FERNE Chairman and President FERNE advisory board for The Medicine Company in May 2007 FERNE advisory board for The Medicine Company in May 2007 No current individual financial disclosures No current individual financial disclosures

6. Case Presentations 35 year old female presents with a diffuse headache that is worse than her normal migraine headache. She states that this is “the worst headache of her life”. She is nauseated and has vomited one time. Her migraine medicines have not helped to resolve the headache pain. 35 year old female presents with a diffuse headache that is worse than her normal migraine headache. She states that this is “the worst headache of her life”. She is nauseated and has vomited one time. Her migraine medicines have not helped to resolve the headache pain.

7. Case Presentations 45 year old female presents with a sudden, severe headache that began while she was lifting weights at the gym. She states that it felt “like someone hit her on the head with a baseball bat”. She has photophobia, vomiting, neck pain, and meningismus on physical exam. 45 year old female presents with a sudden, severe headache that began while she was lifting weights at the gym. She states that it felt “like someone hit her on the head with a baseball bat”. She has photophobia, vomiting, neck pain, and meningismus on physical exam.

8. Key Clinical Questions What are the likely diagnoses and life threats in these two patients? What are the likely diagnoses and life threats in these two patients?

9. Key Clinical Questions What is the best approach to the diagnosis of these two Emergency Department headache patients? What is the best approach to the diagnosis of these two Emergency Department headache patients?

10. Key Clinical Questions What tests must be performed in order to exclude the life threats for these patients so that they can be sent home once the headache has resolved? What tests must be performed in order to exclude the life threats for these patients so that they can be sent home once the headache has resolved?

11. A Negative CT Scan A Negative CT Scan

12. Recommendation Strength Level A recommendations. Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues). Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

13. Recommendation Strength Level B recommendations. Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies). Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).

14. Recommendation Strength Level C recommendations. Level C recommendations. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus.

15. Question 1: Does a response to therapy predict the etiology of an acute headache? Does a response to therapy predict the etiology of an acute headache? Level C recommendations. Level C recommendations. Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache. Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.

16. Question 2: Which patients with headache require neuroimaging in the ED? Which patients with headache require neuroimaging in the ED? Level B recommendations. Level B recommendations. 1. Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (eg, focal deficit, altered mental status, altered cognitive function) should undergo emergent* non-contrast head CT. 1. Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (eg, focal deficit, altered mental status, altered cognitive function) should undergo emergent* non-contrast head CT.

17. Question 2: Which patients with headache require neuroimaging in the ED? Which patients with headache require neuroimaging in the ED? Level B recommendations. Level B recommendations. 2. Patients presenting with new sudden- onset severe headache should undergo an emergent* head CT. 2. Patients presenting with new sudden- onset severe headache should undergo an emergent* head CT.

18. Question 2: Which patients with headache require neuroimaging in the ED? Which patients with headache require neuroimaging in the ED? Level B recommendations. Level B recommendations. 3. HIV-positive patients with a new type of headache should be considered for an emergent* neuroimaging study. 3. HIV-positive patients with a new type of headache should be considered for an emergent* neuroimaging study.

19. Question 2: Which patients with headache require neuroimaging in the ED? Which patients with headache require neuroimaging in the ED? Level C recommendations. Level C recommendations. Patients who are older than 50 years and presenting with new type of headache but with a normal neurological examination should be considered for an urgent† neuroimaging study. Patients who are older than 50 years and presenting with new type of headache but with a normal neurological examination should be considered for an urgent† neuroimaging study.

20. Question 3: Does lumbar puncture need to be routinely performed on ED patients being worked up for non-traumatic subarachnoid hemorrhage whose non-contrast brain CT scans are interpreted as normal? Does lumbar puncture need to be routinely performed on ED patients being worked up for non-traumatic subarachnoid hemorrhage whose non-contrast brain CT scans are interpreted as normal?

21. Question 3: Level B recommendations. Level B recommendations. In patients presenting to the ED with sudden-onset, severe headache and a negative non-contrast head CT scan result, lumbar puncture should be performed to rule out subarachnoid hemorrhage. In patients presenting to the ED with sudden-onset, severe headache and a negative non-contrast head CT scan result, lumbar puncture should be performed to rule out subarachnoid hemorrhage.

22. Question 4: In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study?

23. Question 4: Level C recommendations. Level C recommendations. 1. Adult patients with headache and exhibiting signs of increased intracranial pressure (eg, papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture. 1. Adult patients with headache and exhibiting signs of increased intracranial pressure (eg, papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture.

24. Question 4: Level C recommendations. Level C recommendations. 2. In the absence of clinical findings suggestive of increased intracranial pressure, a lumbar puncture can be performed without obtaining a neuroimaging study. (Note: An LP does not assess for all causes of a sudden severe headache.) 2. In the absence of clinical findings suggestive of increased intracranial pressure, a lumbar puncture can be performed without obtaining a neuroimaging study. (Note: An LP does not assess for all causes of a sudden severe headache.)

25. Questions 5: Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture?

26. Questions 5: Level B recommendations. Level B recommendations. Patients with a sudden-onset, severe headache who have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended. Patients with a sudden-onset, severe headache who have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended.

27. Conclusions Guidelines do provide guidance Clinically relevant clinical questions with specific answers Assists the clinician in decision making Pt outcomes can be optimized Clinical practice enhanced

28. Questions? edsloan@uic.edu 312 317 4996 www.ferne.org ferne_clindec_2010_sloan_clin_policy_headache_062410 5/16/2015 3:38 AM