Patients Presenting to the Emergency Department with Acute Headache

PAIN MANAGEMENT/CLINICAL POLICY C of Adult Patients Presenting to the Emergency Department With From Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Jo Pe St Ta Wy Me Clin An Wy De Ba Jo Fra Jo St Sig Jo J. Stephen Huff, MD Eri Th Do Ed An De An Jim Sc Ed Mo Ro St Ch Da Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies 01 Co doi Vo lume , .  : October  Annals of Emergency Medicine 407 c J. Lavonas, MD omas W. Lukens, MD, PhD nna L. Mason, RN, MS, CEN (ENA Representative 2004-2006) ward Melnick, MD (EMRA Representative 2007-2008) thony M. Napoli, MD (EMRA Representative 2004- 2006) Committee and Subcommittees Approved by the ACEP Board of Directors, June 24, 2008 Supported by the Emergency Nurses Association, July 29, 2008 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 print journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors. 96-0644/$-see front matter pyright © 2008 by the American College of Emergency Physicians. :10.1016/j.annemergmed.2008.07.001 Headache: nathan A. Edlow, MD (Chair) ter D. Panagos, MD even A. Godwin, MD mara L. Thomas, MD att W. Decker, MD mbers of the American College of Emergency Physicians dy S. Jagoda, MD (Chair 2003-2006, Co-Chair 2006- 2007) att W. Decker, MD (Co-Chair 2006-2007, Chair 2007- 2008) borah B. Diercks, MD rry M. Diner, MD (Methodologist) nathan A. Edlow, MD ncis M. Fesmire, MD hn T. Finnell, II, MD, MSc (Liaison for Emergency Medical Informatics Section 2004-2006) even A. Godwin, MD rid A. Hahn, MD hn M. Howell, MD ical Policies Committee (Oversight Committee): vorah Nazarian, MD nMarie Papa, RN, MSN, CEN, FAEN (ENA Representative 2007-2008) Richmann, RN, BS, MA(c), CEN (ENA Representative 2006-2007) ott M. Silvers, MD ward P. Sloan, MD, MPH lly E. W. Thiessen, MD (EMRA Representative 2006- 2008) bert L. Wears, MD, MS (Methodologist) ephen J. Wolf, MD erri D. Hobgood, MD (Board Liaison 2004-2006) vid C. Seaberg, MD, CPE (Board Liaison 2006-2008) Acute Headache the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical linical Policy: Critical Issues in the Evaluation and Management [Ann Emerg Med. 2008;52:407-436.] AB Ph eva em he de an the pa Do pa he (C pa saf ne wi bo rec ava IN Su mi vis 5.5 mu an ou wh pra W de cli tum ho fol 20 cli mu Ot wi co ob the he 74 co we performing a lumbar puncture without a head CT scan in 49 pe 10 we he pa the rec co sus 49 or ph to the em jud wh wh on M cri M Sp un wh lim yea rev pu me art inc me be po ba ava rev ph He Th po thi Joi of Ne co co Cl Clinical Policy 40 STRACT This clinical policy from the American College of Emergency ysicians is an update of a 2002 clinical policy on the luation and management of adult patients presenting to the ergency department (ED) with acute, nontraumatic adache. A writing subcommittee reviewed the literature to rive evidence-based recommendations to help clinicians swer the following 5 critical questions: (1) Does a response to rapy predict the etiology of an acute headache? (2) Which tients with headache require neuroimaging in the ED? (3) es lumbar puncture need to be routinely performed on ED tients being worked up for nontraumatic subarachnoid morrhage whose noncontrast brain computed tomography T) scans are interpreted as normal? (4) In which adult tients with a complaint of headache can a lumbar puncture be ely performed without a neuroimaging study? (5) Is there a ed for further emergent diagnostic imaging in the patient th sudden-onset, severe headache who has negative findings in th CT and lumbar puncture? Evidence was graded and ommendations were given based on the strength of the ilable data in the medical literature. TRODUCTION A query of the National Hospital Ambulatory Medical Care rvey for 1999 to 2001 found that headache accounted for 2.1 llion emergency department (ED) visits (2.2 % of all ED its). Of the 14% of the patients who underwent imaging, % received a pathologic diagnosis.1 Emergency physicians st determine which patients need neuroimaging in the ED d which can be appropriately deferred and evaluated in the tpatient setting. Many patients have limited access to care, ich further complicates this decision process in clinical ctice, but this variable is not accounted for in most studies. hen evaluating the data, the outcome measures used in termining the need for neuroimaging in the ED must also be nically relevant to practice. For example, diagnosing a brain or may not require immediate neurosurgery or even spitalization, yet may clearly direct the disposition and low-up timing of the patient. This policy is an update of the 02 American College of Emergency Physicians (ACEP) nical policy on headache.2 In deciding which test to perform, emergency physicians st assess pretest risk for the condition. Researchers in tawa, Ontario, conducting an observational study in patients th severe headache, asked emergency physicians to rate their mfort level in performing a lumbar puncture without first taining a head computed tomography (CT) scan, as well as ir estimates of pretest probability of a subarachnoid morrhage in these patients.3 Of the 1,070 eligible patients, 7 were prospectively enrolled, with 50 patients having a nfirmed subarachnoid hemorrhage. Emergency physicians re either “uncomfortable” or “very uncomfortable” with 8 Annals of Emergency Medicine .6% of 625 patients. They were “very comfortable” with rforming a lumbar puncture with a head CT scan in only .2% of patients with acute headache. Emergency physicians re better at identifying patients at low risk for subarachnoid morrhage and less accurate at identifying the high-risk tients. Emergency physicians’ estimate of the probability of patient having a subarachnoid hemorrhage revealed a eiver operating characteristic curve with an area of 0.85 (95% nfidence interval [CI] 0.80 to 0.91). The sensitivity of clinical picion was 93% (95% CI 81% to 97%) and specificity was % (95% CI 45% to 53%) using a pretest probability of 2% greater as the threshold. Researchers believed that emergency ysicians discriminate moderately well between headache due subarachnoid hemorrhage and other causes. However, given high mortality associated with a missed diagnosis, ergency physicians are currently unwilling to trust their gment. There were 3 subarachnoid hemorrhage cases in ich pretest probability was 2% or lower, which may explain y many emergency physicians continue to use diagnostic tests patients with low pretest probability.3 ETHODOLOGY This clinical policy was created after careful review and tical analysis of the medical literature. Multiple searches of EDLINE and the Cochrane database were performed. ecific key word/phrases used in the searches are identified der each critical question. To update the 2002 ACEP policy, ich used literature up to December 1999, all searches were ited to English-language sources, human studies, adults, and rs January 2000 to August 2006. Additional articles were iewed from the bibliography of articles cited and from blished textbooks and review articles. Subcommittee mbers supplied articles from their own files, and more recent icles identified during the expert review process were also luded. The reasons for developing clinical policies in emergency dicine and the approaches used in their development have en enumerated.4 This policy is a product of the ACEP clinical licy development process, including expert review, and is sed on the existing literature; when literature was not ilable, consensus of emergency physicians was used. Expert iew comments were received from individual emergency ysicians and from individual members of the American adache Society and the Society for Academic Medicine. eir responses were used to further refine and enhance this licy; however, their responses do not imply endorsement of s clinical policy. This document was also reviewed by the nt Guidelines Committee (JGC) of the American Association Neurological Surgeons (AANS) and the Congress of urological Surgeons (CNS), however, this review does not nstitute an endorsement or approval of the document, its ntent, or conclusions by the JGC, the AANS, or the CNS. inical policies are scheduled for revision every 3 years; Volume , .  : October  however, interim reviews are conducted when technology or the pra gra evi cla de rep an Ar rel ver all val val rec pre of “X po da rev acc rec are fou po pa cri for cer ov stu ma ma (ie ad iss stu ma co lite rec no are ab be do This policy is not intended to be a complete manual on the eva bu par an pro qu qu of im rep em the thi me cru ph pat ad tra CR 1. Pa no eti acu var sou bra wh his dec use pat ful un rat com M cha Clinical Policy Vo ctice environment changes significantly. All articles used in the formulation of this clinical policy were ded by at least 2 subcommittee members for strength of dence and classified by the subcommittee members into 3 sses of evidence on the basis of the design of the study, with sign 1 representing the strongest evidence and design 3 resenting the weakest evidence for therapeutic, diagnostic, d prognostic clinical reports, respectively (Appendix A). ticles were then graded on 6 dimensions thought to be most evant to the development of a clinical guideline: blinded sus nonblinded outcome assessment, blinded or randomized ocation, direct or indirect outcome measures (reliability and idity), biases (eg, selection, detection, transfer), external idity (ie, generalizability), and sufficient sample size. Articles eived a final grade (Class I, II, III) on the basis of a determined formula, taking into account design and quality study (Appendix B). Articles with fatal flaws were given an ” grade and not used in formulating recommendations in this licy. Evidence grading was done with respect to the specific ta being extracted and the specific critical question being iewed. Thus, the level of evidence for any one study may vary ording to the question, and it is possible for a single article to eive different levels of grading as different critical questions answered. Question-specific level of evidence grading may be nd in the Evidentiary Table included at the end of this licy. Clinical findings and strength of recommendations regarding tient management were then made according to the following teria: Level A recommendations. Generally accepted principles patient management that reflect a high degree of clinical tainty (ie, based on strength of evidence Class I or erwhelming evidence from strength of evidence Class II dies that directly address all of the issues). Level B recommendations. Recommendations for patient nagement that may identify a particular strategy or range of nagement strategies that reflect moderate clinical certainty , based on strength of evidence Class II studies that directly dress the issue, decision analysis that directly addresses the ue, or strong consensus of strength of evidence Class III dies). Level C recommendations. Other strategies for patient nagement that are based on preliminary, inconclusive, or nflicting evidence, or in the absence of any published rature, based on panel consensus. There are certain circumstances in which the ommendations stemming from a body of evidence should t be rated as highly as the individual studies on which they based. Factors such as heterogeneity of results, uncertainty out effect magnitude and consequences, strength of prior liefs, and publication bias, among others, might lead to such a wngrading of recommendations. lume , .  : October  luation and management of adult patients with acute headache t rather a focused examination of critical issues that have ticular relevance to the current practice of emergency medicine. It is the goal of the Clinical Policies Committee to provide evidence-based recommendation when the medical literature vides enough quality information to answer a critical estion. When the medical literature does not contain enough ality information to answer a critical question, the members the Clinical Policies Committee believe that it is equally portant to alert emergency physicians to this fact. Recommendations offered in this policy are not intended to resent the only diagnostic and management options that the ergency physician should consider. ACEP clearly recognizes importance of the individual physician’s judgment. Rather, s guideline defines for the physician those strategies for which dical literature exists to provide support for answers to the cial questions addressed in this policy. Scope of Application. This guideline is intended for ysicians working in hospital-based EDs. Inclusion Criteria. This guideline is intended for adult ients presenting to the ED with acute, nontraumatic headache. Exclusion Criteria. This guideline is not intended to dress the care of pediatric patients or the care of patients with uma-related headaches. ITICAL QUESTIONS Does a response to therapy predict the etiology of an acute headache? tient Management Recommendations Level A recommendations. None specified. Level B recommendations. None specified. Level C recommendations. Pain response to therapy should t be used as the sole diagnostic indicator of the underlying ology of an acute headache. Key words/phrases for literature searches: thunderclap headache, te headache, response to therapy, cause or etiology, and iations and combinations of the key words/phrases. Because headache is a common complaint, physicians have ght ways to differentiate the serious life-, limb-, vision-, or in-threatening etiologies from the more benign ones. Defining o can be sent home safely without workup beyond medical tory and physical examination could expedite patient care while reasing patient cost. Anecdotally, some clinicians have tried to a favorable response to medications as an indicator that a ient’s headache is not due to a secondary (serious) etiology. To ly address this question, it is important to understand the derlying pathophysiology of headache and the pharmacologic ionale behind the current concepts in therapy. Current understanding of headache suggests that there is a mon pathway for the pain regardless of the underlying etiology. uch of our understanding about the pathophysiologic racteristics comes from research on migraine. In essence, Annals of Emergency Medicine 409 headache can be caused by (1) distention, traction, or dilation of int lar tra nec irri int tri du mu tri of aff vas ma kn en pe infl ha Ho infl tri ma pe of tha 5-H in ad ma age pre suc wh pro an evi or of ind pu ind evi sec res Th int ket car carbon monoxide–induced headache (sumatriptan),12 cerebral ven an sub cav 2. Pa 1. 2. 3. yea no urg reg en dis dis up stu ED dia var ED tum he ep oth tha pe pa pa cli an lef add rec mo set Clinical Policy 41 racranial or extracranial arteries; (2) traction or displacement of ge intracranial veins or the dural envelope; (3) compression, ction, or inflammation of cranial and spinal nerves; (4) head and k muscle spasm, inflammation, or trauma; (5) meningeal tation; (6) raised intracranial pressure; and (7) disturbance of racerebral serotonergic projections.5 Evidence suggests that headache pain is transmitted by the geminal nerve from the blood vessels of the pia mater and ra mater.6 The exact trigger of the pain may be ltifactorial, but once the trigger occurs, the geminovascular axons are stimulated, resulting in the onset pain and release of neurogenic peptides stored in the erent C fibers innervating cephalic blood vessels. These oactive neuropeptides then stimulate endothelial cells, st cells, and platelets, creating an inflammatory cascade own as “neurogenic inflammation.” Vasodilatation with hanced permeability of plasma proteins follows with a rivascular inflammatory reaction.7 “Neurogenic ammation” within the cephalic tissue is one model that s been proposed as the pathogenic mechanism of headache. wever, selective and potent inhibitors of “neurogenic ammation” have thus far proven ineffective in clinical als. Serotonin (5-HT) receptors are the main focus of pain nagement because they are known to modulate neurogenic ptide release and vasoconstrict dilated dural vessels.8 The goal therapy is to prevent or abort the neurogenic inflammation t occurs as a result of neuropeptide release. Subtypes of the T1 receptor are believed to be the most important receptors the final common pathway of headache. Despite many verse effects, 5-HT is a potent vasoconstrictor, a property that y be a factor in its ability to treat migraines. Pharmacologic nts with an affinity for 5-HT receptors are currently the ferred therapy in acute headache management. Some agents, h as the triptans, are specific agonists at the 5-HT1 receptor, ereas other medications, such as dihydroergotamine, chlorperazine, and metoclopramide, act at a variety of 5-HT d other aminergic receptors.5,9 There are no prospective randomized controlled trials, dence from meta-analysis from randomized controlled trials, well-designed cohort studies to support or refute the practice using response to therapy in nontraumatic headaches as an icator of potential underlying pathologic entities. The only blished data about response to pain medications as an icator of underlying headache etiology is in Class III dence in the form of case reports and case series. Numerous articles have described headaches of varying ondary (serious) etiologies showing clinical improvement or olution of pain in response to many different analgesics. ese conditions include but are not limited to the following: racerebral hemorrhage/subarachnoid hemorrhage (ibuprofen, orolac, prochlorperazine),10 viral meningitis/meningeal cinomatosis (dihydroergotamine and metoclopramide),11 0 Annals of Emergency Medicine ous thrombosis (sumatriptan and various common algesics),13 carotid artery dissection (sumatriptan),14,15 arachnoid hemorrhage (sumatriptan),16,17 and cysts of the um septi pellucidi (indomethacin).18 Which patients with headache require neuroimaging in the ED? tient Management Recommendations Level A recommendations. None specified. Level B recommendations. 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* noncontrast head CT. Patients presenting with new sudden-onset severe headache should undergo an emergent* head CT. HIV-positive patients with a new type of headache should be considered for an emergent* neuroimaging study. Level C recommendations. Patients who are older than 50 rs and presenting with new type of headache but with a rmal neurologic examination should be considered for an ent† neuroimaging study. *Emergent studies are those essential for a timely decision arding potentially life-threatening or severely disabling tities. †Urgent studies are those that are arranged prior to charge from the ED (scan appointment is included in the position) or performed prior to disposition when follow- cannot be assured. Routine studies are indicated when the dy is not considered necessary to make a disposition in the .19 Key words/phrases for literature searches: acute headache, gnostic imaging, CT scan, MRI, emergency department, and iations and combinations of the key words/phrases. The primary focus in obtaining a neuroimaging study in the is to identify a treatable lesion. Treatable lesions include ors, vascular malformations, aneurysms, subarachnoid morrhage, cerebral venous sinus thrombosis, subdural and idural hemat