Evidence‐Based Diagnosis of Nontraumatic Headache in the Emergency Department: A Consensus Statement on Four Clinical Scenarios

Abstract

A multidisciplinary work performed an extensive review of the medical literature and applied the information obtained to commonly encountered scenarios in the ED.

Risk stratification of non-traumatic headache in the emergency department

“…The Italian multidisciplinary workgroup published in 2004 a statement founded on four clinical evidencebased scenarios corresponding to the commonest situations encountered in clinical practice [6] with the aim of providing practical recommendations for the diagnostic management of non-traumatic headache to ED physicians. The assumption is that limited and simple clinical scenarios to which reconduct each patient could be a more applicable clinical approach in the initial evaluation of headache, with respect to what it is actually recommended in the literature on this topic.…”

“…Although the likelihood of a serious condition may decrease after a normal CT scan, a range of conditions remains which cannot be excluded without further tests [8]. Thus, we considered as reference standard also a telephone follow-up at least three months after the ED access, which in turn should reveal the clinical worsening that usually is associated with conditions such as venous thrombosis, artery dissection or occlusion, neoplasms or small sentinel bleedings [9] that may be disclosed only by MRI or MR angiography or lumbar puncture [6]. The interviewer was unaware of the scenario assignment by the ED physician at recruitment; the interview was performed following a structured questionnaire evaluating the evolution of the headache which led the patient to the ED, the occurrence of new symptoms, new attendance at an ED or admission to hospital, and the execution of other diagnostic tests.…”

“…Before receiving results of diagnostic tests, information was recorded on a specific data collection form. Once the scenario was assigned, the ED physician was suggested to follow the recommended diagnostic procedures as previously published [6]. However, according to the Ethical Committee, the physician was free to select the best patient management s/he deemed appropriate in that clinical situation.…”

“…1). Algorithm details have been described [6]. In brief, scenario 1 aimed to include sudden stabbing headache attacks associated with SAH or other causes of "thunderclap headache"; scenario 2 aimed to include headaches that may be the expression of central nervous system or systemic infections; scenario 3 aimed to include long-lasting and/or worsening headache possibly associated with brain tumours or temporal arteritis; scenario 4 aimed to include benign headaches that are referred to the ED because attacks fail to respond to usual therapy.…”

Cefalea en urgencias

“…Los hallazgos de la anamnesis y la exploración física detalladas van a permitir identificar los denominados criterios "de alarma" (Tabla 2) que sugieren una etiología secundaria 10,12,13 . Los síntomas de alarma más importantes son que el dolor se inicie de forma súbita, tras esfuerzos físicos o maniobras de Valsalva, y que tenga un carácter explosivo.…”