Scope of Application This guideline is intended for physicians working in emergency departments who are evaluating nontraumatic patients with acute onset headache and nonfocal neurologic examination findings.
Inclusion Criteria This guideline is intended for acute adult nontraumatic headaches.
Exclusion Criteria This guideline is not intended for patients with chronic headaches or pediatric, pregnant, or trauma patients.
Critical Questions
In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?
Level B Recommendations:
Use the Ottawa Subarachnoid Hemorrhage Rule (≥40 years, complaint of neck pain or stiffness, witnessed loss of consciousness, onset with exertion, thunderclap headache, and limited neck flexion on examination) as a decision rule that has high sensitivity to rule out subarachnoid hemorrhage, but low specificity to rule in subarachnoid hemorrhage, for patients presenting to the emergency department with a normal neurologic examination result and peak headache severity within 1 hour of onset of pain symptoms.
Although the presence of neck pain and stiffness on physical examination in emergency department patients with an acute headache is strongly associated with subarachnoid hemorrhage, do not use a single physical sign and/or symptom to rule out subarachnoid hemorrhage.
In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications?
Level A Recommendation:
Preferentially use nonopioid medications in the treatment of acute primary headaches in emergency department patients.
In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage?
Level B Recommendation:
Use a normal noncontrast head computed tomography* performed within 6 hours of symptom onset in an emergency department headache patient with a normal neurologic examination, to rule out nontraumatic subarachnoid hemorrhage. *Minimum third-generation scanner.
In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage?
Level C Recommendations:
Perform lumbar puncture or computed tomography angiography to safely rule out subarachnoid hemorrhage in the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography result.
Use shared decision making to select the best modality for each patient after weighing the potential for false-positive imaging and the pros and cons associated with lumbar puncture.
Disclaimer Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.
