Many patients presenting to the ED with a primary presenting of feature of headache will have serious pathology. In Virchester audits the number with serious disease (tumour, bleeding, meningitis etc.) has remained at about 10% for many years. Our job as emergency physicians is to identify those with life threatening disease and also to help those with lesser disease burden, but who may still require care. Key to this is actively ruling out the life-threatening and life-changing diagnoses:
- Subarachnoid Haemorrhage
- Tumours and Space Occupying Lesions
- Temporal Arteritis
Listen to Simon and Iain discuss how to approach these patients here
More here from the superb Sarah Robinson reiterating some of the key points.
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Sudden onset headache (classically patients who feel as though they’ve been hit on the back of the head) or onset during exercise
First and worst – headache in patients who don’t have frequent headaches or migraines and severe headache particularly if described as “the worst headache of my life”
Headaches in the context of fever or seizure
Headaches which are worse during exercise or present on waking
A thorough examination including a neurological exam which is clearly documented is essential here – and remember some patients with serious underlying causes may have subtle defects that they can describe but which you might not be able to elicit on examination – this doesn’t mean they are making it up!
Patients with concerning headache features are worth speaking to a senior doctor about. Deciding not to CT these patients is a tricky decision and we should expect the majority of these scans to be normal (that doesn’t mean it shouldn’t have been performed!) so in the presence of any red flag features definitely discuss with a senior about a scan – and if you are concerned about other patients they should be discussed too.
Lumbar puncture is pretty controversial – and not a decision you are going to make without senior input!
Blood tests probably aren’t going to be that useful unless you think the patient might have temporal arteritis in which case elevated inflammatory markers.
Don’t be reassured by normal blood tests – in fact, if you think it might be meningitis you shouldn’t be waiting for blood results at all. Early antibiotics save lives so if you are concerned enough to be considering antibiotics then it’s better to give the antibiotics – don’t be the doctor who writes “?meningitis” in the notes and does nothing else! As ever, if you’re concerned your seniors are there to help.
Headaches at Life in the Fast Lane – a great summary from the LiTFL crew
Headache from the Flipped EM Classroom