Acute Headache in the Emergency Setting

Guryildirim, Melike; Kontzialis, Marinos; Ozen, Merve; Koçak, Mehmet

doi:10.1148/rg.2019190017

Cited by 16 publications

(16 citation statements)

References 90 publications

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“…Work-up proposals made by radiologists describe all of the differential radiological etiologies that can be found (31), including small dural arteriovenous fistulas, arteriovenous malformations, arterial dissections, colloid cysts at the third ventricle, and cerebral venous sinus thromboses. Many of these cannot be completely ruled out without completing all aforementioned imaging modalities, and sometimes it is even necessary to repeat imaging after 3 months (31)(32)(33).…”

Section: Discussionmentioning

confidence: 99%

Management of thunderclap headache in the emergency room: A retrospective cohort study

et al. 2021

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Introduction The evaluation of red flags is crucial for the accurate the diagnosis of headache disorders, especially for thunderclap headache. We analysed if secondary headache disorders were adequately ruled out in patients that presented to the emergency room with thunderclap headache. Methods In this retrospective cohort study, we screened all patients that visited the emergency room for headache, including those that described thunderclap headache. We measured the frequency with which secondary causes were not adequately ruled out. We analysed the order of the exams, the final diagnosis, and the time elapsed between arrival, initial request for imaging, and the completion of the imaging. Results We screened 2132 patients, and 42 (1.9%) fulfilled eligibility criteria. Mean age was 43.1 ± 17.1 years, and 57% of patients were female. For 22 (52.4%) patients, the work-up was incomplete. Vascular study was missing in 16 (38.1%) patients, cerebrospinal fluid evaluation in nine (21.4%), and magnetic resonance imaging in seven (16.7%), with multiple assessments missing in six (14.3%). There were ten different combinations in which the exams were performed, with the most frequent being the second exam’s cerebral spinal fluid evaluation in 18 (52.9%) and the computed tomography angiogram in 10 (29.4%). A secondary cause of thunderclap headache was found in 16 (38.1%) patients, and four (9.5%) had a primary headache diagnosis after an adequate and complete study. Conclusions Thunderclap onset was described in one of every 50 patients that visited the emergency room for headache. More than half of these patients were not adequately managed. More than a third of thunderclap headache patients had a secondary cause.

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Section: Discussionmentioning

confidence: 99%

Management of thunderclap headache in the emergency room: A retrospective cohort study

et al. 2021

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“…Severe acute headache with maximum intensity at onset with visual disturbances, nausea, and or vomiting is the characteristic feature of pituitary apoplexy. (81) Head trauma, pregnancy, hypotension, anticoagulants, surgery, pituitary dynamic testing, irradiation and hypertension are the precipitants for apoplexy. Rapid enlargement results in increased pressure of the intrasellar contents.…”

Section: Headache Due To Pituitary Apoplexymentioning

confidence: 99%

“…Rapid enlargement results in increased pressure of the intrasellar contents. (81) There has also been reports of status migrainosus like presentation with gradual onset, unremitting throbbing headache with nausea, phonophobia, and mild photophobia of several weeks duration. (82) Meningeal irritation is caused by dural stretching by mass effect, and extravasation of blood and necrotic tissue into the subarachnoid space.…”

Section: Headache Due To Pituitary Apoplexymentioning

confidence: 99%

“…(82) Meningeal irritation is caused by dural stretching by mass effect, and extravasation of blood and necrotic tissue into the subarachnoid space. (81,83) Pressure increase in sella turcica causes superior compression of the optic tracts, chiasm or nerves and brain stem leading to altered levels of consciousness. Lateral compression of the oculomotor cranial nerves causes diplopia.…”

Section: Headache Due To Pituitary Apoplexymentioning

confidence: 99%

“…(81) Headache intensifies when there is rupture of the hematoma into the subarachnoid space and will be associated with neck stiffness and other signs of meningeal irritation (79) It can be associated with vomiting and also that the patient may have depression. (80,81) Spontaneous non traumatic ICH is presumably an end result of small vessel diseases which include arteriolosclerosis, lipohyalinosis, and cerebral amyloid angiopathy (81) The intraparenchymal mass stretches the pain-sensitive vascular, meningeal, and neural structures and as hematoma enlarges there is increase in ICP due to obstruction of CSF flow. Cerebellar hemorrhages are characterised by occipital headaches followed rapidly by vomiting, impaired consciousness, and brainstem, cerebellar or cranial nerve dysfunctions.…”

Section: Intracerebral Hemorrhagementioning

confidence: 99%

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Classification of Head, Neck, and Face Pains First Edition (WHS-MCH1): Position paper of the WHS Classification Committee

Thomas¹,

Kumar²,

Subir³

et al. 2021

HMC

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The WHS classification of Head, Neck and Face pain, Edition 1 Version 1 (WHS-MCH1) is the official document of the World Headache Society. It was conceptualized and developed by the Society's Classification Committee. The work began with a clean slate to create a comprehensive, updated and holistic classification of headache disorders; where 'headache' was defined as any pain above the shoulders, thus including head, neck and face pain. This new classification reflects a scientifically robust understanding of disease and also places patient experience in the qualia of pain. It is a training manual to be used at the bedside and office as an aid to the diagnosis and management of headache disorders. The dynamic nature of this first ever live classification of headaches also means that ultra-rapid updates, or versions, will be available electronically. It is not a disease criteria but a classification criteria (1) and is useful to pick extended spectra and 'mimickers' of diseases. Although increased sensitivity usually comes at the expense of reduced specificity, an expanded spectrum of diseases in this case also means increased specificity. WHS-MCH1 is a syndromic classification. A syndrome is a recognizable complex of symptoms and physical findings which may have more than one aetiology. Although disease is nominalist and culture-relativistic (2) , a syndrome based approach reflects the discipline of first widening the view of possibilities before analysing each to formulate a diagnostic hypothesis. Such an approach provides a useful framework for organizing the complexity of clinical experience in order to derive inferences about outcome and guide decisions about treatment. WHS-MCH1 has a vertical grouping designed for use by clinicians of all levels of experience; this is linked to the horizontal groupings which are syndrome-based. The syndrome groups are also interlinked to one another. This design enables clinicians to efficiently create the 'big picture' so as not to miss any diagnosis. Axis 1 and 2 are the vertical and horizontal grouping categories, respectively. Axis 3 is the patient narrative of bothersome symptoms and level of impairment. Axis 4 are biomarkers that may be derived from investigations and this is the best example of the continuum of better understanding of disease defining markers. Axis 5 is an objective impairment scale that clinicians may choose based on availability. The World Headache Society hopes that the use of such a robust and inclusive framework will lead to better patient outcomes and improved patient and clinician satisfaction with the investigative and diagnostic process.

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Diagnostic yield of emergency MRI in non-traumatic headache

et al. 2022

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Purpose Non-traumatic headache is one of the most common neurological complaints in emergency departments. A relatively low diagnostic yield of magnetic resonance imaging (MRI) among outpatients has been previously reported, but studies of emergency patients are lacking. We sought to determine the diagnostic yield of emergency MRI among outpatients presenting to the emergency department with non-traumatic headache. Methods In this retrospective cohort study, we analyzed emergency MRI referrals in a tertiary hospital for non-traumatic headache over a five-year period. We recorded patient characteristics, relevant clinical information from the referrals, and imaging outcomes. Results In total, 696 emergency patients with non-traumatic headache underwent MRI, most within 24 h of presentation. Significant findings related to headache were found in 136 (20%) patients, and incidental findings in 22% of patients. In a multivariate model, the predisposing factors of the significant findings were age, smoking, nausea, and signs/symptoms of infection. The protective factors were numbness and history of migraine. A predictive clinical score reached only moderate performance. Conclusion Although emergency MRI shows headache-related findings in one in five patients, accurate prediction modeling remains a challenge, even with statistically significant predictors and a large sample size.

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Acute Headache in the Emergency Setting

Cited by 16 publications

References 90 publications

Management of thunderclap headache in the emergency room: A retrospective cohort study

Management of thunderclap headache in the emergency room: A retrospective cohort study

Classification of Head, Neck, and Face Pains First Edition (WHS-MCH1): Position paper of the WHS Classification Committee

Diagnostic yield of emergency MRI in non-traumatic headache

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