Though patients often present to the ED seeking relief from headaches that cause significant pain and suffering, 90% of them can be considered ?benign.? It is essential to identify the 10% of headache patients who are in danger of having a life-threatening disorder presenting with a sudden and severe headache to ensure that they are treated quickly and effectively.
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Points from the Evaluation and Management of Life-Threatening Headaches in the Emergency Department (Stroke CME and Pharmacology CME):
- The most common life-threatening causes of headaches are subarachnoid hemorrhage (SAH), cervical artery dissection (CAD), cerebral venous thrombosis (CVT), idiopathic intracranial hypertension (IIH), giant cell arteritis (GCA), and posterior reversible encephalopathy syndrome (PRES), and pre-eclampsia.
- SAH is commonly caused by aneurysm rupture; 75% present with abrupt onset. Administer nimodipine in aneurysmal SAH to improve outcomes. The use of prophylactic antiepileptic drugs is controversial.
- CAD is commonly associated with trauma and connective tissue disorders. Treat extracranial dissections with IV heparin followed by warfarin or a direct oral anticoagulant. Treat intracranial dissections with aspirin or clopidogrel.
- CVT presents as a gradual-onset headache that is often the result of thrombotic disease and spreading facial infections. Treat with low-molecular weight heparin or heparin bridge to warfarin. Consider broad-spectrum antibiotics if an infectious etiology is suspected.
- IIH is associated with obese women of childbearing age as well as hypervitaminosis A. Lumbar puncture (LP) is both diagnostic and therapeutic for IIH. Open-ing pressures will be = 25 mm H2O. Acetazolamide is a first-line pharmacotherapy.
- ESR and CRP are poor screening tests for GCA. Biopsy should be obtained in those with high suspicion for GCA after treatment has already been begun.
- Consider a D-dimer to exclude CVT in low-risk patients.
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Last Updated on January 26, 2023
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