Attitudes and Judgment of Emergency Physicians in the Management of Patients with Acute Headache

Abstract

Objectives: There is little evidence guiding physicians in the evaluation of acute headache to rule out nontraumatic subarachnoid hemorrhage (SAH). The authors assessed emergency physicians in: 1) their pretest accuracy for predicting SAH, 2) their comfort with not ordering either head computed tomography (CT) or lumbar puncture (LP) in patients with acute headache, and 3) their comfort with not ordering head CT before performing LP in patients with acute headache. Methods: This two-and-a-half-year prospective cohort study was conducted in three tertiary care university emergency departments with 51 emergency physicians. Consecutive patients more than 15 years of age with a nontraumatic, acute headache (onset to peak headache less than one hour) and normal results on neurologic examination were enrolled. Patients known to have cerebrospinal fluid shunt, aneurysm, or brain neoplasm, and patients with recurrent headaches of the same intensity/character as their current headache were excluded.Physicians recorded their pretest probability for SAH and their comfort with performing either no tests or an LP without first obtaining head CT. Results: The authors enrolled 747 patients (mean age 42.8 years; 60.1% female; 77.0% their worst headache; 83.4% had CT and/or LP), including 50 (6.7%) with SAHs. Physicians reported being ''uncomfortable'' or ''very uncomfortable'' with performing no test in 75.4% of cases and being ''uncomfortable'' or ''very uncomfortable'' with performing LP without CT in 49.6% of cases. The area under the receiver operating characteristic (ROC) curve for SAH was 0.85 (95% CI = 0.80 to 0.91). Conclusions: Physicians were able to moderately discriminate SAH from other causes of headache before diagnostic testing.

Missed Diagnosis of Subarachnoid Hemorrhage in the Emergency Department

“…Whereas clinical judgment is likely to play an important role in the accurate diagnosis of SAH in the ED, 26 standardization of the diagnostic approach to potential SAH patients may not fully address the problem. Current efforts to derive a clinical decision rule to rule out SAH in headache patients have been carried out among patients attending teaching hospital sites, 32,33 and the effectiveness of rules could be limited if their implementation or interpretation varies between community and teaching hospitals.…”

Is Important a Diagnostic Dilemmas Section on the European Position Paper on Rhinosinusitis and Nasal Polyps 2012 (Epos 2012)?

“…Overall mortality is 25% in 24 hours and 50% within six months. Of the survivors, 42% are left with neurologic sequelae (Perry et al, 2005).…”

“…ASAH has an annual incidence of 1 to 2.5 per 10,000 persons. It occurs in young people, with a median age of 50 years (Perry et al, 2005).…”

“…However, in up to one third of patients with ASAH symptoms or signs consist of headache alone. The majority, over 70%, are diagnosed as having benign headaches (tension, cluster), migraines or RS (Perry et al, 2005).…”

Secondary Headaches

“…Evaluation typically includes imaging studies and a spinal fluid examination (Table 3.7). In an interesting study, ED physicians evaluated 747 headache patients, 77% of whom reported this was their "worst headache" [16]. SAH was eventually diagnosed in 50 of these patients.…”