EMERGENCY DEPARTMENT EVALUATION OF HEADACHE

To determine whether unenhanced CT alone could be sufficient for the screening of patients admitted with a suspicion of secondary headache in an emergency center.

A feasibility study including consecutive patients admitted to our emergency department for acute non-traumatic headache, in whom a brain CT was required by the emergency physician, was conducted over a 3-month period of time. Patients with a suspicion of intracranial pathology, which can only be depicted by i.v. images (arterial dissection, venous thrombosis, or postoperative complication) were recorded but excluded from analysis. All patients underwent both unenhanced and i.v. enhanced cerebral CT, including CT angiography. Unenhanced CTs were reviewed by two radiologists, blinded to the clinical data, to the radiological reports and to the i.v. enhanced images. Unenhanced CT were sorted by the radiologists into three groups: (1) normal CT, (2) benign finding that could explain headache without need of injection of contrast media, (3) evidence of an intracranial pathology, requiring further imaging. Results were compared to i.v. enhanced CT images.

A brain CT was required in 105 patients (34 males, 71 females) during the study period, 74 (70%) of them met our inclusion criteria. Fifty-nine (80%) were sorted in group 1 (normal), four (5%) in group 2, 11 (15%) in group 3. No further finding that could explain acute headache was found on i.v. CT images in patients of group 1 or 2. A significant pathology was confirmed by i.v. CT in all patients of group 3.

This feasibility study suggests that a normal unenhanced CT might be sufficient to exclude the cause of headache in the initial screening of a selected group of patients admitted with cephalalgia. It compels researchers to perform further prospective studies to confirm the current data on a larger amount of patients.

In the acute setting, the primary objective is to decide whether the headache is primary, secondary but benign (for example a headache associated with a cold), or secondary to a potentially life-threatening cause (subarachnoid hemorrhage (SAH), bacterial meningitis, intracranial hypertension). The cornerstone of headache diagnosis is the interview with the patient, followed by a thorough physical examination. These two first clinical steps determine the need for investigation, immediate with inpatient care or on an outpatient basis, and the treatment to recommend, acutely and for future attacks in the case of primary headache. The indication for referral to a neurologist for long-term follow-up is assessed.

Headaches can be separated into four groups: (1) recent onset and thunderclap; (2) recent onset with progressive installation: (3) well known to the patient and episodic (attacks with headache-free periods, as in episodic migraine or cluster headache); and (4) chronic daily headaches (more than 3 months, more than 15 days of headache per month). Headaches with a recent onset and judged unusual or worrisome by the patient (even one with frequent headaches) must raise the suspicion of a secondary cause and need to be investigated. Headaches that continue for months or years are more often primary, but secondary causes need to be ruled out in certain cases.

We sought to determine whether the manner and order in which historical questions used to risk stratify for subarachnoid hemorrhage are asked significantly alter the response/concordance.

Adult patients complaining of headache in the emergency department were presented with 1 of 2 questionnaires each containing 2 variations of the pertinent question and differing only in their order. Data were primarily analyzed using the κ statistic to determine whether rates of concordance are greater than would be expected by chance alone. And, as a secondary outcome, a sample of 120 was predetermined to be adequate to achieve 80% power in detecting a difference of 20% to 25% between questionnaires comparing the influence of order on concordance.

The agreement corrected for chance for version 2, κ = 0.51, is higher than the agreement corrected for chance for version 1, κ = 0.28, a difference of 0.23 with a 95% confidence interval (−0.03 to 0.49; P = .08; SE, 0.13). The percentages of patients who answered the questions concordantly were 60% and 75%, respectively, for versions 1 and 2. The difference is 15% with a 95% confidence interval of (−2% to 32%, P = .08).

Although not statistically significant, our study indicates that up 38% answer these 2 very similar questions discordantly. Also, there appears to be a higher degree of concordance (15%) when patients are first asked, “When was the last time you had a headache this bad?”

Les céphalées constituent un des motifs les plus fréquents de consultation. Leurs causes sont extrêmement diverses. Il est très important dans un premier temps de préciser les caractéristiques de la douleur et les signes d’accompagnement afin de distinguer les céphalées primaires ne nécessitant pas d’examen d’imagerie et dont les causes les plus fréquentes sont les migraines et les céphalées de tension, des céphalées secondaires attribuées à une cause organique et nécessitant des explorations plus approfondies. En cas de suspicion de céphalées secondaires ou symptomatiques, l’imagerie tient une place très importante dans le bilan étiologique. Son objectif en urgence est de rechercher une affection susceptible d’engager le pronostic vital.

Headaches constitute one of the most frequent reason of consultation. Their causes are extremely varied. The first step consists in the analysis of the characteristics of the pain and the associated signs in order to distinguish primary and secondary headaches. Primary headaches, including migraines and tension-type headaches are the most frequent types and do not require imaging evaluation. Secondary headaches are related to an organic cause and require specific investigations. In case of suspected symptomatic or secondary headaches, brain imaging plays an important role in the etiologic work-up. The main purpose of imaging in an emergency setting is to diagnose a life-threatening disease.