ACEP Guidelines on Acute Nontraumatic Headache Diagnosis and Management in the Emergency Department, Commentary on Behalf of the Refractory, Inpatient, Emergency Care Section of the American Headache Society

Abstract

The American College of Emergency Physicians (ACEP) published guidelines in July 2019 on the diagnosis and management of acute nontraumatic headaches in the emergency department, focusing predominantly on the diagnosis of subarachnoid hemorrhage and the role of imaging and lumbar puncture in diagnosis. The ACEP Clinical Policies document is intended to aide Emergency Physicians in their approach to patients presenting with acute headache and to improve the accuracy of diagnosis, while promoting safe patient care practices. The Clinical Policies document also highlights the need for future research into best practices to distinguish primary from secondary headaches and the efficacy and safety of current treatment options for acute headaches. The following commentary on these guidelines is intended to support and expand on these guidelines from the Headache specialists’ perspective, written on behalf of the Refractory, Inpatient, Emergency Care section of the American Headache Society (AHS). The commentary have been reviewed and approved by Board of Directors of the AHS.

Lost diagnoses in not otherwise specified headache in Emergency Department

“…The problem of under-diagnosis or misdiagnosis of primary and secondary headache in ED was largely investigated from the perspective of neurology and emergency medicine, and several flow-charts were made to improve the diagnostic accuracy, especially regarding potentially dangerous secondary headache [10][11][12]. The role of EPs is crucial in the first assessment of a headache complaint and has two major responsibilities: to treat painful headache and to discover its underlying causes.…”

Headache Characteristics in the Neurological Emergency Department: A Retrospective Study

“…Guidelines and a concept of warning symptom “red flags” are classically used to help ED physicians with the challenging task of distinguishing between primary and secondary headache. ( 14 – 16 ) Munoz-Ceron additionally suggests predictors of a primary headache as “green flags” ( 33 ) based on the ICHD-3 classification.…”

“…Trauma in the medical history was even associated with a 41-fold increased risk of secondary headache. Therefore trauma, cardiovascular and respiratory diseases in patient history should also be considered “red flags,” especially since they are not yet mentioned in corresponding guidelines, except for malignancy in the medical history ( 14 – 16 ). Munoz-Ceron et al assume in their study that it is not meaningful to determine frequently observed symptoms in the case of primary headache in outpatient departments, such as nausea, vertigo, photo- and phonophobia and pain intensity, and found no statistically significant correlations with concomitant symptoms ( 33 ).…”

An Evaluation of Medication Prescribing Patterns for Acute Migraine in the Emergency Department: A Scoping Review

“…Several of the extracted studies have stated a lack awareness as a primary contributor to high rates of opiate prescription for migraine headache [17,21,25,27,30]. Specifically, a lack of awareness or familiarity or knowledge of alternative medications or the harms which opiates pose to migraineurs.…”

“…Specifically, a lack of awareness or familiarity or knowledge of alternative medications or the harms which opiates pose to migraineurs. An acknowledgement of the importance of education and awareness was expressed in 5 of the extracted studies [17,21,25,27,30]. Regarding triptan prescription practices, of the extracted studies two noted that no parenteral triptans were used as they were not stocked in the pharmacy, and an additional two studies noted that triptan prescription was under 1%.…”