Headache – Assessment

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Headache

ACUTE HEADACHE

(this section does not consider traumatic causes of headache)

  • Consider early CT brain if rapid onset of headache to rule out expanding space-occupying lesion particularly if there is altered mental state or focal neurological deficit
  • In severely depressed conscious state then early airway protection is required
  • Abrupt onset of severe (‘thunderclap’) should be considered a sub-arachnoid haemorrhage until proven otherwise
  • Do not send a patient with rapidly deteriorating conscious state unescorted for imaging
  • Note that a normal plain CT brain does not rule out a number of important causes of acute headache
  • Consider important non-intracranial sources of headache

Red flags

ASSESSMENT

See Acute Headache Assessment Form (printable form)
Examination

  • Vital signs especially fever or Cushing’s reflex
  • GCS
  • A careful neurological examination including gait, coordination and reflexes
  • A test of higher cortical functions e.g. speech
  • Evaluate cognition via the mini-mental state examination
  • Examine the head for non-intracranial pathology

COMMON TRAPS

  • Ignoring any headache in an anti-coagulated patient
  • Considering a normal plain CT brain rules out all serious pathology

INVESTIGATIONS

Depending on clinical assessment, severity of symptoms and likelihood of acute pathology
Routine blood tests are usually not helpful unless there are specific suspicion

  • WCC/CRP (if infective process suspected)
  • ESR/CRP (if temporal arteritis suspected)

High patient risk groups

DISPOSITION

Immediate CT brain

  • Rapidly deteriorating conscious state
  • Focal deficit

Early CT brain

  • Rapid onset of acute headache
  • Headache different or ‘worst ever’ from previous episodes

Prolonged observation

Moderate headache with

Discharge Criteria

  • Afebrile
  • Normal GCS
  • No focal deficit or other neurological symptoms
  • No signs of Raised Intracranial Pressure
  • Mild symptoms
  • Normal CT brain if high-risk patient

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