Acute Headache: Who should we CT?

Steven A. Godwin, MD, FACEPAssistant Professor

Program Director

Department of Emergency Medicine

University of Florida HSC/Jacksonville

“When the headaches, all the body is worse”

-English Proverb

Case Presentation

• 35 year old female presents to the emergency department with sudden onset of severe headache after stating she had been outside reading all day in the sun. She admits to taking 2 of a friend’s hydroxycodone and now is feeling better. Her physical exam is normal.

• Does she need a CT scan?

Background• Headache accounts for 1% of all ED visits

in the US (1 million patients/year)1

• An estimated 1-4% of all patients presenting to the ED with headache complaint have emergent or urgent diagnosis1,2

1 Dhopesh V, Anwar R, Herring C. A retrospective assessment of emergency department patients with complaint of headache. Headache. 1979;19:37-42 (Retrospective review; 872 patients)

2 Ramirez-Lassepas M, Espinosa C, Cicero J, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 1997;54:1506-1509. (Retrospective

review; 329 patients)

How do we narrow down which patients need further studies?

• History– Presentation of ominous headaches vary but

important factors that provide a clue for the clinician include:

• Severity

• Onset

• Quality of pain

• Associated symptoms

What Is the Goal of Neuroimaging in the ED?

• To identify a treatable lesion.• ACEP and AAN have categorized neuroimaging

– Emergent- essential for a timely decision regarding potentially life-threatening or severely disabling entities

– Urgent- arranged prior to discharge from the ED or, performed prior to disposition when follow-up cannot be assured

– Routine- indicated when the studies results are not considered to make a change in the patients disposition from the ED

Practice Guidelines:What is the evidence?

• In 1994, AAN published “Practice Parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination”

3 American College of Neurology. Practice parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination. Neurology. 1994;44:1353-1354.

AAN 1994 Guidelines

– Evidence based recommendations1. Neuroimaging is not warranted in patients with

migraine presenting with a typical event

2. Neuroimaging should be considered in patients with atypical headaches, history of seizures, or focal neurologic findings

3. Insufficient evidence to define role of MRI vs CT in headache patients without a migraine

The 2000 US Headache Consortium

• Reviewed articles dealing with chronic headache

Key findings:• Abnormality on neurologic exam increased the

likelihood of positive results with neuroimaging by 3 fold (95% CI 2.3 to 4.0)

• Normal findings with a neurologic exam reduced the odds of positive findings in a neuroimaging study by 30%

4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000

The US Headache Consortium Conclusions

1. Neuroimaging should be considered in patients with nonacute headache and an unexplained abnormality on neurologic examination

2. Insufficient evidence to make neuroimaging recommendations based on the presence or absence of neuro finding (in patients with chronic headache

3. Neuroimaging is not warranted in typical migraine and no neuro findings

4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000

The US Headache Consortium Conclusions

4. Insufficient evidence to make neuroimaging recommendations in patients with tension-type headaches

5. Insufficient data for evidence-based recommendations regarding CT versus MRI in the evaluation of nonacute headache

4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000

Predictors of Intracranial Pathology in Patients with Headache

• Retrospective random chart review of 468 patients presenting with chief complaint of headache– Abnormal neurologic exam had a 39% PPV for

intracranial pathology– Age greater than 55 was associated with

increase risk of intracranial process– No association found between type of HA and

the final diagnosis

2 Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol. 1997;54:1506-1509 (III)

“Sudden Worst Headache”

Is this predictive?

• One retrospective study found a 29% yield for positive head CT in patients complaining of “worst headache” but no correlation with diagnosis of subarachnoid hemorrhage4

• Harling et al. in a prospective study of patients presenting with thunderclap headache found 35/49 to have SAH on CT or LP5

5 Mills ML, Russo LS, Vines FS, et al. High yield criteria for urgent cranial computed tomography scans. Ann Emerg Med. 1986;15:1167-1172 (III)

6 Harling DW, Peatfield RC, Van Hille PT, et al Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90 (II)

“Sudden Worst Headache”

• Prospective study of 27 patients – All patients had acute sudden-onset HA with

normal neurologic findings – All patients had CT, if negative an LP was

performed and were then followed for 3 months– 9 patients had SAH, 1 intraventricular

hemorrhage, 1 bacterial meningitis, 1 with viral meningitis

7 Lledo A, calandre L, Marinez-Menendez B, et al. Acute headache of recent onset and subarachnoid hemorrhage: a prospective study. Headache. 1994;34:172-174 (I)

“Sudden Worst Headache”Some studies have failed to demonstrate a

significant correlation• One retrospective review of 333 ED patients

complaining of acute or acutely worsening HA – 17 patients had “worst headache of life”; only one had positive CT

results7

• Another study found only 1/27 patients with “worst headache complaint to have intracranial pathology8

8 Reinus WR, Wippold FJ, Erickson KK. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache. Emerg Radiol. 1994;94:67-70(II)

9 Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache.1993;33:82-86 (III)

Headache in HIV Related Disorders

Prospective study• 49 consecutive HIV patients with headache

– 82% had a serious identifiable cause.

• HIV positive patients with headache should be considered for CT and LP

10 Lipton RB, Feraru ER, Weiss G, et al. Headache in HIV Related Disorders. Headache. 1991;31:518-522 (II)

ED Utilization of Noncontrast Head CT in HIV Infected Patients

• Prospective convenience sample of 110 HIV patients with neurologic complaints– New seizure, depressed or altered mental status, and

headache that was different in character or lasted longer than 3 days

• New or different HA was reported in 25% of the cases

• All cases of focal lesions identified

11 Rothman RE, Keyl PM, McArthur JC, et al . A decision guideline for the utilization of noncontrast head CT in HIV infected patients. Acad Emerg Med. 1999;6:1010-1019 (II)

Patient Management Recommendations

• Level A Recommendations – None

• Level B Recommendations– Patients presenting to the ED with headache

and abnormal findings on neurologic examination should undergo emergent noncontrast head CT.

– Patients presenting with acute sudden-onset headache should be considered for emergent head CT scan.

– HIV positive patients with a new type of headache should be considered for urgent neuroimaging study.

Patient Management Recommendations

• Level C Recommendations – Patients who are older than 50 years old with a

new type of headache without abnormal finding on neurologic exam should be considered for urgent neuroimaging.

Gracias!

References1 Dhopesh V, Anwar R, Herring C. A retrospective assessment of emergency department patients with

complaint of headache. Headache. 1979;19:37-42 (Retrospective review, 872 patients; III)

2 Ramirez-Lassepas M, Espinosa C, Cicero J, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 1997;54:1506-1509. (Retrospective review, 329 patients; III)

3 American College of Neurology. Practice parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination. Neurology. 1994;44:1353-1354. (Evidence based guidelines, (III)

4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology. 2000 (Evidence based review, II)

5 Mills ML, Russo LS, Vines FS, et al. High yield criteria for urgent cranial computed tomography scans. Ann Emerg Med. 1986;15:1167-1172 (Prospective, 407 patients; III)

6 Harling DW, Peatfield RC, Van Hille PT, et al Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90 (Prospective, 49 patients; II)

References7 Lledo A, calandre L, Marinez-Menendez B, et al. Acute headache of recent onset and

subarachnoid hemorrhage: a prospective study. Headache. 1994;34:172-174 (Prospective, 27 patients; I)

8 Reinus WR, Wippold FJ, Erickson KK. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache. Emerg Radiol. 1994;94:67-70(Retrospective, 333 patients; II)

9 Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache.1993;33:82-86 (Prospective, 350 patients; III)

10 Lipton RB, Feraru ER, Weiss G, et al. Headache in HIV Related Disorders. Headache. 1991;31:518-522 (Prospective, 49 patients; II)

11 Rothman RE, Keyl PM, McArthur JC, et al . A decision guideline for the utilization of noncontrast head CT in HIV infected patients. Acad Emerg Med. 1999;6:10101-1019 (Prospective, 110 patients; II)