Headaches

Although the cause of severe headaches in patients presenting to the ED are typically of benign etiology, there are serious and even life-threatening causes for which the EP should retain a high index of suspicion. In the physician’s thoughts lurk the small, but real, possibility that a missed diagnosis might lead to harm or even death of the patient. The cause of the headache may not be detectable during the ED visit—even after expensive, time-consuming, and, sometimes painful, studies. Fears of being charged with negligence or malpractice may be hovering somewhere in the back of an EP’s mind. Additionally, the goals of the physician and the patient may not be aligned (eg, the patient is often more concerned with symptom relief, while the physician is typically more concerned with rapid diagnosis and diagnostic accuracy).

The patient with chronic or recurrent headache presents a special management challenge. The EP may encounter the same patient at repeat ED visits. Assessment of pain—the “fifth vital sign”—and response of interventions are frequently the subjects of review by accreditation and regulatory organizations.¹ A patient with pain from recurrent headache may not be completely satisfied during a visit, and this may be reflected in the ED’s patient satisfaction scores. On the other hand, the epidemic of prescription pain medication misuse has become a nationally recognized problem, and EPs in particular are being tasked to carefully assess opioid administration and prescriptions.² In addition, chronic opioid administration may interfere with patient response to some headache-specific medications such as triptans.³ Cautious prescribing with screening before utilizing controlled substances in patients at risk is recommended to prevent misuse and abuse.⁴

Literature History

Much of the literature on headaches comes from pain and headache clinics and reflects the experience from that patient population. Patients referred to such clinics often have chronic, recurrent headaches that are difficult to manage. The consultation and referral processes at these centers exclude many time-sensitive causes of headache, and extensive neuroimaging and other studies likely will have detected patients with tumors and vascular lesions. In the nomenclature of headaches, these clinics specialize in treating patients with primary headache syndromes (eg, migraine, cluster, chronic daily headache). Conversely, secondary causes of headache are infrequent in these clinics. Studies based on these patient populations conclude that serious secondary causes of headaches are uncommon, reflecting ascertainment bias in these settings.

Secondary Causes of Headache

Diagnostically, the goal of the EP must be to detect or exclude serious secondary causes of headaches (sometimes referred to as headaches with organic causes), including headaches from tumors, vascular lesions, infections, and causes of increased intracranial pressure (ICP) such as:

• Pseudotumor cerebri (benign increased ICP)
• Meningitis
• Brain abscesses
• Dissections of the cranial and cervical vessels
• Aneurysms (both ruptured and unruptured)
• Arteriovenous malformations
• Dural sinus thromboses
• Inflammatory processes
• Vasculitis
• Traumatic hematomas (both acute and chronic).

This long list represents just some of the serious etiologies of headaches. While these processes are uncommon, they are not rare in the ED population, and the EP will encounter patients with each of these conditions during his or her career—along with the challenge to rapidly detect these potential life threats against the background of the very common primary or functional headaches. Thus, the EP is clearly placed in a dilemma: He or she needs to be thorough in diagnosing and treating the headache patient quickly without missing a serious etiology. History and physical examination can never be perfect in detecting all serious headaches, and even a lengthy, thorough, and time-consuming neurological examination will not detect all serious causes.

Neuroimaging

Neuroimaging is used liberally because computed tomography (CT) and magnetic resonance imaging (MRI) continue to detect findings not expected from the sometimes insensitivity of history-taking and physical examination. However, balanced against the need for thorough evaluation are concerns for expense and unnecessary radiation exposure.

Several recent high-visibility media posts note the overutilization of neuroimaging and the lack of physician adherence to guidelines.^5-7 Yet, without imaging studies proving the case prior to admission, when patients present with high-risk symptoms and abnormal physical-examination findings, reimbursement for further investigation and hospitalization may be retrospectively denied. The author recently was involved in the care of a patient who arrived by aeromedical transport in a stroke-alert scenario with abrupt onset of headache, physical findings of left-sided weakness, and medical conditions that placed the patient at high-risk for stroke. After the hospitalization was over and investigations were completed, the insurance carrier concluded:

The information received does not show that the member’s headaches were due to suspected organic causes or findings requiring hospitalization and therapeutic intervention…. Treatment of this member could be provided at a less intensive level of care or in another setting, such as a nursing facility, outpatient setting or home.... This plan does not cover services that are not medically necessary.” (Personal written communication with Aetna Health Inc, January 22, 2014.)