Title: Acute Nontraumatic Headache: CT/LP or Not?<br/>Author: WanTsu Wendy Chang<br/><a href='http://umem.org/profiles/faculty/1322/'>[Click to email author]</a><hr/><ul>
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<span style="font-size:14px;">The ACEP clinical policy on the evaluation and management of acute nontraumatic headache in the ED was recently updated.</span></li>
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<span style="font-size:14px;">Similar to prior policies, it focuses on the diagnosis of subarachnoid hemorrhage (SAH) due to the disproportionate amount of literature in comparison to other high risk etiologies.</span></li>
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<span style="font-size:14px;">In summary:</span></li>
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<span style="font-size:14px;"><u>Are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?</u></span>
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<span style="font-size:14px;">The Ottawa SAH Rule has a high sensitivity but low specificity for patients presenting with a normal neurological exam and peak headache intensity within 1 hour of symptom onset (<i>Level B recommendation</i>).</span></li>
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<span style="font-size:14px;">Caution in application of this rule, as use in the incorrect population may increase unnecessary testing.</span></li>
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<span style="font-size:14px;"><u>Are nonopioids preferred to opioids for treatment of acute primary headache?</u></span>
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<span style="font-size:14px;">Preferentially use nonopioid medications in the treatment of acute primary headaches in ED patients (<i>Level A recommendation</i>).</span></li>
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<span style="font-size:14px;">Consider discharge medication and education to reduce headache recurrence and repeat ED visit.</span></li>
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<span style="font-size:14px;"><u>Does a normal noncontrast head CT performed within 6 hours of headache onset preclude the need for further diagnostic workup for SAH?</u></span>
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<span style="font-size:14px;">Noncontrast head CT using at least a 3rd generation scanner performed within 6 hours of headache onset can be used to rule out nontraumatic SAH (<i>Level B recommendation</i>).</span></li>
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<span style="font-size:14px;">If clinical suspicion remains high despite the negative noncontrast head CT, further evaluation may be pursued.</span></li>
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<span style="font-size:14px;"><u>In a patient who is still considered to be at risk for SAH after a negative noncontrast head CT, is CTA as effective as LP to rule out SAH?</u></span>
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<span style="font-size:14px;">Use shared decision making to select the best modality for each patient after weighing the potential for false-positive CTA and the pros/cons associated with LP (<i>Level C recommendation</i>).</span></li>
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<span style="font-size:14px;">This clinical policy does not address the evaluation of other potential etiologies for acute headache, including in the pregnant woman and postpartum woman. </span></li>
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<fieldset><legend>References</legend>
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<span style="font-size: 14px;">Godwin SA, Cherkas DS, Panagos PD, </span><i style="font-size: 14px;">et al</i><span style="font-size: 14px;">. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. </span><i style="font-size: 14px;">Ann Emerg Med</i><span style="font-size: 14px;"> 2019;74(4):e41-74. </span></p>
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<em><strong><span style="font-size: 14px;">Follow me on Twitter @EM_NCC</span></strong></em></p>
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