Clinical Policy
Clinical policy: Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache*,**,*,**,*,**

https://doi.org/10.1067/mem.2002.120125Get rights and content

Abstract

This clinical policy focuses on critical issues in the evaluation and management of patients with acute headache. A MEDLINE search was performed, abstracts were reviewed, and appropriate full-text articles were read; references from reviewed articles were searched for additional material. This policy focuses on 4 areas of current interest and/or controversy in acute headache management: (1) response to headache therapy as an indicator of underlying pathology, (2) clinical findings predictive of increased intracranial pressure, (3) indications for emergent neuroimaging in patients with a complaint of headache, and (4) indications to pursue emergent diagnostic studies in patients with thunderclap headache but with normal findings on a head computed tomography (CT) scan and negative findings on a lumbar puncture. Recommendations for patient management are provided for each of these 4 topics based on strength of evidence. Level A recommendations represent patient management principles that reflect a high degree of clinical certainty, Level B recommendations represent patient management principles that reflect moderate clinical certainty, and Level C recommendations represent other patient management strategies based on preliminary, inconclusive, or conflicting evidence, or based on panel consensus. This guideline is intended for physicians working in hospital-based emergency departments. [American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med. January 2002;39:108-122.]

Introduction

Headache is a common complaint for which patients seek emergency department care. The diagnoses for patients with headache range from non–life-threatening processes such as migraine to life-threatening conditions such as subarachnoid hemorrhage (SAH). Missing a life-threatening condition may result in adverse patient outcomes and may also pose the potential for medicolegal liability. For these reasons, the American College of Emergency Physicians (ACEP) chose headache as a clinical policy topic. The original headache clinical policy was published in June 1996.1 The format of the initial headache clinical policy focused on the evaluation of a patient presenting with a chief complaint of headache as opposed to specific disease processes. It was a broad-based attempt to focus on key history, physical, and diagnostic findings to drive the diagnosis of potentially serious medical conditions with emphasis on SAH, meningitis, and carbon monoxide poisoning. Because of the all-inclusive nature of the previous policy, the format did not allow specific emphasis on critical issues in the evaluation of selected subsets of headache patients.

The Clinical Policies Committee believes that the format of the previous complaint-based clinical policy has gone as far as possible in directing the appropriate evaluation and treatment of patients presenting with headache. The committee is satisfied that the previous policy met the original goals of ACEP. This has been exemplified by the use of clinical policies to direct physician education and research, its use by quality improvement personnel in individual hospitals, its use in medical malpractice cases for establishing a reasonable standard of care, and its use by private companies in creating templates for physician history and physicals. A decision was made to develop a revised policy that focuses on critical issues in the evaluation and management of patients with a chief complaint of acute headache. It is hoped that departure from the previous format will improve patient care and direct critical areas of future research.

This policy is not intended to be a complete manual on the initial evaluation and management of patients with headache. Specifically, some areas of interest to the practicing emergency physician were not addressed because committee members believed either that there was not enough evidence to pursue an analysis of the topic or that the topic had been extensively discussed in recent literature and did not warrant additional discussion at this time. An example of this is the sensitivity of computed tomography (CT) in diagnosing SAH.2

The reasons for developing clinical policies in emergency medicine and the approaches used in their development have been enumerated.3 This policy is a product of the ACEP clinical policy development process, including expert review, and is based on the existing literature. Expert review comments were received from emergency physicians; physicians from other specialties, such as neurologists; and specialty societies, including members of the American Academy of Family Physicians, American Academy of Neurology (AAN), American Headache Society, American Society of Neuroimaging, and the National Headache Foundation. Their responses were used to further refine and enhance this policy. Clinical policies are scheduled for revision every 3 years; however, interim reviews are conducted when technology or the practice environment changes significantly.

This clinical policy was created after careful review and critical analysis of the peer-reviewed literature. A MEDLINE search for articles published between January 1966 and December 1999 was performed using combinations of the following key words: headache and pathophysiology, or mechanisms: lumbar puncture or spinal tap, or dural puncture and herniation, or complications, or headache, or subarachnoid hemorrhage: headache and computed tomography, magnetic resonance imaging, or diagnostic testing: thunderclap headache and diagnostic testing or subarachnoid hemorrhage. Searches were limited to English-language sources. Additional papers were reviewed from the bibliography of articles cited. Recent journals and standard texts were also examined for additional sources.

Pertinent articles were selected from the reviewed abstracts and from bibliographies of initially selected papers. Publications were stratified by at least 2 of the subcommittee members into 1 of 3 categories of strength of evidence according to the following criteria:

  • Strength of evidence Class I —Interventional studies including clinical trials, observational studies including prospective cohort studies, aggregate studies including meta-analyses of randomized clinical trials only.

  • Strength of evidence Class I I—Observational studies including retrospective cohort studies, case-controlled studies, aggregate studies including other meta-analyses.

  • Strength of evidence Class III —Descriptive cross-sectional studies, observational reports including case series and case reports, consensus studies including published panel consensus by acknowledged groups of experts.

Strength of evidence Class I and II articles were then rated on elements the committee believed were most important in creating a quality work. Class I and II articles with significant flaws or design bias were downgraded from 1 to 3 levels based on a set formula. Strength of evidence Class III articles were downgraded 1 level if they demonstrated significant flaws or bias. Articles downgraded below a Class III strength of evidence were given an “X” rating and were not used in formulating this policy.

Articles were assembled into evidentiary tables that were used to answer the 4 questions posed in this clinical policy, and recommendations regarding patient management were then made according to the following criteria:

  • 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 the issues).

  • 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).

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

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

This guideline is intended for physicians working in hospital-based EDs.

Section snippets

Background

Because headache is a common complaint, physicians have looked for ways to differentiate the life-threatening etiologies from the more benign ones. Defining who can be sent home safely without further work-up could improve patient care while decreasing patient cost. Review of the literature suggests that some clinicians have tried to use response to medications as an indicator of the seriousness of a patient’s headache. To fully address this question, it is important to understand the

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    *

    Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.

    **

    This clinical policy was developed by the ACEP Clinical Policies Subcommittee on Acute Headache and the ACEP Clinical Policies Committee.

    *

    Members of the Clinical Policies Subcommittee on Acute Headache included:

    **

    Members of the Clinical Policies Committee included:

    *

    Approved by the ACEP Board of Directors, September 11, 2001.

    **

    Rhonda Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

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