Headache is a common presenting complaint in Australian Emergency departments. The vast majority of presentations are benign however lurking in this sea of well patients are a few with life threatening illnesses. The key challenge as an emergency physician is differentiating these benign and serious presentations. A thorough and precise history is the cornerstone of good decision making here .
The 'red flag' approach to headache that most of us learn in medical school is a good foundation to build upon.
Serious / do not miss
SAH / ICH
Meningitis / Encephalitis / Cerebral Abscess
Giant cell arteritis / Tempral arteritis
(Hypertensive encephalopathy / pre-eclampsia)
Other facial pain - toothache, sinusitis etc.
Idiopathic intracranial hypertension
Other less common headache syndromes (eg: Cluster)
History - Very important!
Red flags that may warrant further investigation
-Sudden Onset (Ie 'felt like someone hit me in the back of the head;') +Careful how you ask this question
-First headache or most severe headache
-Bleeding risk (eg anticoagulant)
-Infection risk (eg immunosupression)
-Age > 50
Focus on Vitals, Temperature,, signs of meningism and neurological examination - Rarely abnormal but abnormal neurological examination makes sinister pathology likely.
Don't forget the temporal arteries in the > 50's.
Not routine! but targeted to exclude life threatening Dx
Bedside: HCG if pregnancy possible
Blood: Rarely contributory - ESR useful when considering temporal arteritis (>50)
CT and LP
-Approach to excluding meningitis
-Approach to excluding SAH
CT within 6 hours for SAH
Emergency Medicine - Cadogan & Brown
Rosen's - Chapter on headache